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A MANUAL OF DISEASES 



OF THE 



NOSE, THROAT, AND 
EAR 



BY 

K B. GLEASON, M.D», LL.D. 

ii 

Clinical Professor of Otology in the Medico-Chirurgical College ; Aurist to the 

Medico-Chirurgical Hospital ; Surgeon-in-Charge of the Nose, Throat, 

and Ear Department of the Northern Dispensary ; Formerly 

one of the Laryngologists to the Philadelphia Hospital 



Illustrated 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 

1907 



^ 



LIBRARY of CONGRESS 
Two Cooles Received 
MAY 11 f90r 
/] CopyrirM Entry 

CLASS /^ xxc, no; 

CWY B. ' ' 






Copyright, 1907, 
By W. B. SAUNDERS COMPANY 



ELECTROTYPED BY 
WESTCOTT & THOMSON, PHILADA, 



PRESS OF 
SAUNDERS COMPANY 



TO 

Hon. IHcnri? f. Malton, 

Pkf.sidknt of the Meuico-Chirurgical College and Hospital, 
Philadelphia 

A LEARNED, GENIAL GENTLEMAN 

AND 

A GOOD FRIEND 

IN AFFECTIONATE APPRECIATION OF HIS MANY ACTS 

OF KINDNESS AND WORDS OF WISE COUNSEL 

THIS LITTLE BOOK IS INSCRIBED 

BY 

THE AUTHOR 



PREFACE 



This manual was written to supply students and general 
practitioners with the essential facts of Rhinology, Laryn- 
gology, and Otology in as concise a form as possible. 

The more important facts of the anatomy, physiology, 
and pathology of the upper respiratory tract and ear 
have received careful consideration, so that the volume 
might prove sufficiently complete for study or reference 
by undergraduates during their college years and for 
practitioners taking a post-graduate course in laryn- 
gology and otology. 

The details of inspection, examination, and diagnosis of 
the nose, throat, and ear conditions and the use of the 
commoner instruments of diagnosis and for the making 
of applications have received very careful and compara- 
tively lengthy detailed description. The same may be 
said of minor operations. Methods of treatment have 
been simplified as much as possible, so that in most in- 
stances only those methods, drugs, and operations have 
been advised which, by the actual experience of the 
author, have proved essential to the accompHshment of 
the desired result. At the end of the book is a collec- 
tion of Formulas designed to represent more than a mere 
catalogue of prescriptions. Hence a detailed description 
of the better methods of use of each of the more im- 
portant drugs has been interpolated, which it is hoped 
the reader will find useful and suggestive. 

13 



14 PREFACE 

The history of the gradual development of some of 
the more important instruments, methods of treatment, 
and, more especially, operations has been considered 
of sufficient practical importance to be briefly outlined. 
In some instances the prognosis in cases not operated 
on has been accentuated by quotations from the writ- 
ings of standard authors of the period before such 
operations were practised. 

The book contains 262 engravings, a considerable 
proportion being original or drawn from dissections 
made by the author. The value of carefully made 
sections through the upper respiratory tract and ear 
for purposes of study and reference is stated and a 
method of preparing and preserving such specimens 
described. 

E. B. GLEASON. 
Philadelphia, May, 1907. 



CONTENTS 



PAGE 

The LAKYN(ioscoPE 17 

The Art of Laryngoscopy 22 

Laryngeal Image 29 

Rhinoscopy 33 

Otoscopy 39 

Accessory Instruments 45 

Sterilization of Instruments 58 

Examination of Patients 61 

The Nose 64 

Anatomy of the Nose 64 

Physiology and Pathology of Mucous Membranes and " Catching 

Cold" 69 

Inflammation of Mucous Membranes 70 

Diseases of the Nose 73 

Diseases of the Nasal Septum 128 

Diseases of the Accessory Sinuses 159 

The Pharynx 184 

Anatomy of the Pharynx 184 

Diseases of the Nasopharynx or Postnasal Space 188 

Diseases of the Oropharynx 194 

The Tonsils 214 

Diseases of the Tonsils 214 

Diseases of the Uvula 225 

The Larynx 229 

Anatomy of the Larynx 229 

Diseases of the Larynx 239 

15 



1 6 CONTENTS 

PAGE 

The Ear 293 

Anatomy of the Ear 293 

The External Ear 293 

The Middle Ear 294 

The Internal Ear or Labyrinth 303 

Tests for Hearing 308 

Pathologic Conditions of Nose and Pharynx Causing Disease of Ear 318 

Diseases of External Ear 329 

Cutaneous Diseases of the Auricle 333 

Diseases of the External Auditory Canal 341 

Diseases of the Middle Ear 360 

The Membrana Tympani 360 

Diseases of the Tympanum 373 

Systemic Diseases Causing Otic Inflammation 410 

Operations upon the Middle Ear 415 

Intracranial Complications of Otic Disease 475 

Diseases of the Perceptive Apparatus 489 

Formulas 494 

Index 537 



DISEASES OF 
THE NOSE, THROAT, AND EAR 



THE LARYNGOSCOPE 

The laryngoscope is a combination of two mirrors 
arranged to enable the observer to see the interior of the 
larynx. The larger and concave mirror, called the reflector, 
is attached to the observer's head by a head-band, and the 
smaller and plane mirror, called the laryngeal mirror, is 
introduced into the back part of the mouth in such a manner 
as to be directly above the glottis ; so that light reflected 
from the reflector upon the laryngeal mirror illuminates the 
interior of the larynx, and enables the observer to see its 
image in the small mirror. 

In 1854 Signor Manuel Garcia, by means of a dentist's 
mirror and a hand-glass, studied the movements of his own 
vocal cords during phonation, and accurately described the 
registers of the voice in a paper read before the Royal 
Society of London in 1855, and hence the honor of invent- 
ing the laryngoscope is usually accorded to Garcia. In 
1857 Tiirck, of Vienna, began to use the laryngeal mirror 
on his patients, and he and Czermak, who substituted arti- 
ficial light for sunlight, improved their apparatus until the 
laryngoscope was perfected to the form that is used at the 
present day. 

The laryngeal mirror consists of an oval or round piece 
of silvered glass, mounted in a metal frame and attached to 
a wire stem at an angle of not less than 120 degrees. Such 
mirrors vary in size from \ inch to \\ inches in diameter, 
and are numbered i, 2, 3, 4, 5 by instrument-makers. 
However, smaller mirrors, Nos. 00 and o, and larger mirrors. 
2 17 



DISEASES OF THE NOSE, THROAT, AND EAR 





Nos. 6, 7, and 8, may be obtained, and are occasionally 

useful. The wire stem is either fixed in a handle or slides 

into a hollow handle of metal, and 

is clamped at any desired length by 

a set-sere vv (Fig. i). 

The reflector is a concave mirror 
3 J inches in diameter, of about 12- 
inch focus, and made of silvered 
glass, mounted in a metal frame, so 
arranged that it is capable of attach- 
ment by a universal joint either to a 
head-band or the source of illumi- 
nation. 

The instrument known as Fox's 
head-band (Fig. 2) consists of four 
steel or, preferably, brass strips, 
because steel, though lighter, readily 
corrodes. The metal strips are 
hinged together so that they can 
be folded about the mirror, so as to 
protect it and form such a small 
and conveniently shaped package 
that both head-band and mirror 
readily can be carried in a pocket of 
the surgeon's clothing. When in 
use the head-band assumes the 
position of a line passing over the 
head from the forehead to the occi- 
put. It is held firmly in position by 
the hinged bands, which when un- 
folded act as a spring. It has the 
advantage that at once it adjusts 
itself to heads of varying shapes 
and sizes, and hence is convenient 
in class-demonstration to pass from student to student. 
However, a head-band of leather is decidedly the preferable 
instrument, because it is lighter. The leather should be 
black to prevent discoloration by sweat. Head-bands 
of rubber elastic are soon corroded by sweat from the 
forehead and are rendered useless. The joint by which 




Fig. I. — Laryngeal mirror in 
universal handle. 



TJIE LAR YNGOSCOPE 



19 



the mirror is attached to the forehead is by no means a 
matter of indifference, a double ball-and-socket joint f^reatly 
facilitates the adjustment of the reflected light, and' renders 
it possible to bring the perforation in the center of the 




Fig. 2. — Reflector with Fox's head-band. 



reflector closer to the eye, a decided advantage in examining 
narrow cavities like the nasal passages or the auditory 
meatus. Some years ago the author had made for use in 
his class-room the head-band shown in Fig. 3. At that time 




Fig. 3. — Gleason's head-band. 



his principal object was cheapness. The instrument, how- 
ever, proved so light, comfortable, and efficient that it has 
become his favorite head-band. 

Proper Method of Wearing the Reflector. — The reflector 
should be worn upon the forehead over the left eye, and the 



20 DISEASES OF THE A'OSE, THROAT, AND EAR 



light should be reflected from it upon the face of the patient, 
so as to form a circle, bounded above by the tip of the 
nose and below by the front of the chin. When worn over 
the left eye, with the source of illumination to the left of 
the patient, it is possible to secure a better illumination of 
the nose and mouth with less frequent manipulation of the 
reflector. If, how^ever, the source of illumination be at the 
patient's right, the reflector is more conveniently worn over 
the right eye. 

The sources of light used in otoscopy are natural and 
artificial. 



^ 



-Mi^ 



mm 





Fig. 4. — Light concentrator, with reflector. 

Daylight, preferably that reflected from a white cloud, or 
artificial light, furnished by an Argand burner fed by oil or 
gas, or the electric light, is now generally used. Whatever 
the source of the illumination, the light is directed into the 
auditory canal, mouth, or nose by means of the reflector. 

Tobold, Mackenzie, and others invented light concentra- 
tors, where convex lenses are used, to concentrate the light 
upon the reflector. Such an apparatus, containing one or 
more lenses and made to fit over a student's lamp or 
Argand burner, can be obtained in the instrument stores. 
The apparatus shown in Fig. 4 is perhaps the best of these, 
and may be used either over an ordinary student's lamp, 
Argand burner, Welsbach light, or the electric light can be 
placed within the apparatus. The bull's-eye lens shown in 
the figure is advantageously replaced by a disk of plain 
glass, such as is used in bicycle lamps, and the reflector 



THE LARYNGOSCUPK 2 I 

brought much nearer the hunp. The Welsbach \vg\\\. gives 
by far the most satisfactory illumination, but because of tlic 
frequent moving of the bracket the mantle, which should 
be used without a glass chimney, has a much shorter life 
than if the light were stationary. However, in spite of 
this disadvantage, the Welsbach light is probably the best 
for office work and the Argand burner for the dispcnsar)- 
or elsewhere when the lamp is liable to rough handling. 
The electric light, after it has passed through the lens and 
been reflected by the mirror, yields a bright image of the 
filament with deep intervening and surrounding shadows. 
To overcome this difficulty, Veeder had the filament made 
into the form of a disk. 



Fig. 5. — Adjustable gas bracket. 

As shown in Fig. 4, the reflector is attached to the light 
concentrator in such a manner that it will reflect light into 
the nose, mouth, or ear, and thus do away with the necessity 
of wearing the reflector upon the forehead. This arrange- 
ment is a decided advantage, because a forehead reflector 
if worn all day is apt to result in a headache. 

The source of light should be at the patient's right (Fig. 7), 
somewhat behind him, and on a level with the top of his ear. 
As the heights of patients vary greatly when seated, it is well 
to have some means by which the position of the light can 
be quickly and conveniently changed. There are several 
forms of adjustable gas brackets manufactured that answer 
fairly well. One that can readily be manipulated with the 
left hand while the operator remains seated will be found to 



22 DISEASES OF THE NOSE, THROAT, AND EAR 

be the most convenient. That shown in Fig. 5 has large 
conic bearings which do not wear loose so rapidly and 
leak as some of the other patterns. 

THE ART OF LARYNGOSCOPY 

Laryngology is the art of seeing and describing what is 
seen in the larynx. The word signifies a treatise on the 
larynx and its diseases. Laryngoscopy is simply the art of 
viewing the interior of the larynx. 





Fig. 6.— Diagram illustrating the principle of the laryngoscope (Lennox Browne). 

The optical law involved in laryngoscopy is that tlie angle 
of reflection is equal to the angle of incidence. 

This law is illustrated by the fact that the laryngeal 
mirror must be placed in the back part of the patient's 
mouth, above and behind the larynx, and at such an angle 
that light received on its surface is reflected downward into 
the larynx. The rays then forming the laryngeal image 
will return along the same path, and be reflected at the 
same angle into the eye of the observer. From this it 
follows that the nearer the center of the head-mirror is 
placed to the eye of the observer, the better will the image 
of the larynx be seen (Fig. 6), 



THE L A R ) 'NC OSC 'OPE 



23 



Wc should bear in niincl tluit the huyn<^cal iiiia^c^c is a 
reflected one, and that, therefore, it is reversed antero- 
posteriorly, owin^ to the fact that the hirync^eal mirror is 
above and behind the openin^^ of the larynx (Fii^. 8j. 

The observer should sit opposite to the patient, so that 
his eye is on a level with, and about a foot from, the mouth 
of the patient, whose head should be slightly raised and 
inclined backward. The knees of the observer should be 




Fig. 7. — Technic of laryngoscopy (Sahli). 



either at the left or on either side of the patient's knees. For 
office use it is most convenient to have piano stools, which 
can be raised or lowered, so that the difference in the heights 
of different patients can be compensated for, and the eye 
of the observer can be brought on a level with that of the 
patient ; while the patient's head may rest upon a cushioned 
framework fastened to the wall. AH ordinary piano stools 



24 DISEASES OF THE NOSE, THROAT, AND EAR 

are not especially ornamental. Chairs of various designs 
have been manufactured. Most of these for ordinary office 
work are less convenient than two piano stools, which can 
be made of ornamental design and luxurious appearance, 
while a padded wall affords an efficient head-rest for the 
patient. 

If a head-reflector be used, it is advisable for the observer 
first to place his head in an easy position, and then move 
the reflector until the disk of reflected light falls in the 
opened mouth of the patient with its center at the base of 
the uvula, thus illuminating all the surrounding parts. This 
method of procedure has the very practical advantage that 
if the observer has to turn his head to see 
to pick up an instrument or for any other 
purpose, bringing his head back into the 
former easy position at once reilluminates 
the patient's pharynx without readjusting 
he reflector. 

Introduction of Laryngeal Mirror. — The 

laryngeal mirror is first warmed by holding 

its reflecting surface over a flame for a 

^ T short time to prevent moisture condensing 

\/ upon it. The handle should be held be- 

^ tween the thumb and forefinger of the 

Fig. 8.-Diagram of right hand Hkc a pcn-holdcr, with the re- 

laryngeal mirror, illus- n .• r r A^ • i i 

trating the reversion iiectmg surfacc of thc mirror downward. 
fLnnox Br'owner^' ^^^ forcarm should bc flexed upon the 
arm and the hand slightly backward upon 
the wrist and held a Httle below the mouth of the patient. 
By a forward motion of the hand and a slight raising 
of the arm and unbending of the elbow the mirror should 
be quickly carried into the mouth, following the curve 
of the hard palate until the back of the mirror touches 
and raises the uvula, pressing it upward and backward 
as far as possible. Meanwhile the left hand of the observer 
has grasped the patient's protruding tongue, holding it 
well forward by means of a towel or napkin to prevent 
slipping through the fingers. 

Controlling the Tongue. — The protruded tongue of the 
patient should be grasped between the outstretched thumb 




THE LARYNGOSCOPE 25 

and indcx-fingcr of the left hand, i)rotcctcd by a napkin or 
towel to prevent sHppin<^, in sueh a manner that the fore- 
fini^er bein^- [)hieed ai^ainst the lower teeth, projects above 
their edge, and thus forms a roller upon which the tongue 
can move without its frenum coming in contact with the 
sharp edge of the lower incisors. The thumb being placed 




Fig. 9. — Method of making a laryngoscopic examination (Anders). 

on the upper surface of the tongue and the middle finger 
above the chin of the patient, a slight rotatory motion of 
the observer's left hand will then not only control the 
motion of the tongue of the patient, but also keep all 
involuntary movements of his head in check, as the bit in 
a horse's mouth controls the animal's action. When the 
operator has to use both hands in operating or making 



26 DISEASES OF THE NOSE, THROAT, AND EAR 

applications, the patient should be taught this maneuver and 
requested to hold his tongue forward himself. 

The mirror should not touch the tongue or palate ; and, 
when in position, it should be held steadily and not allowed 
to tremble, or gagging as well as retching will result 
Should the slightest sign of this occur, the mirror must be 
quickly withdrawn, and only reintroduced when the patient 
has had time to recover his breath and confidence ; or the 
gagging will be repeated on an attempt to reintroduce the 
mirror, and the throat finally become so sensitive that a 
further examination will be impossible at that sitting. 

To bring the laryngeal image into view the handle of the 
mirror is brought to one side until it lays in the angle of 
the patient's mouth, and the hand holding it is steadied by 
one or two fingers resting on the cheek of the patient. This 
procedure brings the hand out of the Hne of vision. The 
mirror is next slowly but steadily turned until the image of 
the larynx appears upon its surface. The patient should 
now be requested to say " Ah," in order to cause a rising 
of the epiglottis and bring the glottis into view (Fig. 9). 

The temperature of the mirror should always be tested by 
laying the back of the mirror against the skin of the hand, 
and never against the cheek ; because a sHght abrasion of 
the skin of the cheek easily escapes notice, and may be 
inoculated with specific poison by the back of the mirror, 
which has previously come in contact with the secretions 
of a patient suffering from specific disease. 

Obstacles to larjmgoscopy are: i. Irritability of the phar- 
ynx, produced by trembling of the hand holding the mirror, 
causing gagging and retching. 2. Want of proper ^(^V/i-/- 
ment of the light, without which the larynx cannot be illu- 
minated, even when the mirror is in the proper position. 3. 
Undue irritability or peculiar formation of certain parts of 
the throat. 4. Raising of the back of the tongue upon 
the approach of the mirror, in spite of the traction made 
upon its tip. 5. Too large or pendent epiglottis. 

Gagging and retching can generally be prevented by 
avoiding to touch the tongue and palate while introducing 
the mirror, and by holding it steadily in its proper position 
when introduced. Irritability of the pharynx may be re- 



TIIK L A R YNG O SCOPE 



27 



lievcd by letting the patient swallow a glass of ice-water 
before introducing the mirror; or, if that should fail, the 
use of a spray of cocain solution from an atomizer will 
generally produce the desired effect. If the back part of 
the tongue rises so as to obstruct the view, in spite of trac- 
tion on its tip, it may be caused to lie flat in the mouth by 
steady pressure with a tongue-depressor (Figs. 10-12). 
When the epiglottis is too large or pendent, so as to obstruct 
the view, we can sometimes see the glottis by causing the 
patient to laugh or sing in a high pitch. 




Fig. io. — Folding tongue-depressor. 



Fig. II. — Turck's tongue-depressor. 



Autolaryngoscopy. — The observer who wishes to study his 
own larynx should seat himself with his back toward a 
window through which the direct light of the sun enters. 
In front of him should be a plane mirror, so placed as to 
reflect a ray of sunlight into his open mouth. All being in 
readiness, he seizes his tongue with a napkin held in his left 



28 DISEASES OF THE NOSE, THROAT, AND EAR 

hand, and pulls it forward. His right hand now carries a 
laryngeal mirror to the back of the mouth, its progress 
being watched in the mirror before him. When properly 
placed, the sunlight from the plane mirror is reflected by the 
laryngeal mirror into the larynx, and its image appears 
upon the laryngeal mirror and is reflected forward upon 
the plane mirror, where it may be studied by the observer. 
Artificial light may also be used for autolaryngoscopy by 



Fig. 12.— Bosworth's tongue-depressor. 

having the source of illumination at one side of, on a level 
with, and slightly behind the observer's head ; while a con- 
cave reflector is placed at one side of the plane mirror to 
reflect the light upon the laryngeal mirror in the back part 
of the mouth. 

Infraglottic Laryngoscopy. — In some cases in which trache- 
otomy has been performed and the cannula is fenestrated, 
a small mirror may be so introduced into the cannula as 
to obtain a view of the under surface of the vocal cords, 



rilE LARYNGOSCOrE 



29 



which arc red instead of white. Unfortunately, tlic mirror 
must be so small that little else can usually be seen. 

LARYNGEAL IMAGE 

Normal Image. — At the upper part of the mirror (Figs. 1 3- 
15) is seen the reddish-yellow arch of the epiglottis (l) with 
its cushion (c). In front of the epiglottis and extending 
downward across the mirror are seen two pairs of bands — 




Fig. 



-The larynx in gentle breathing (Lennox Browne). 





Fig. 14. — The larynx in tone-production 
(Lennox Browne). 



Fig. 



-The larynx in deep breathing 
(Lennox Browne). 



the outer red, and the inner of a pearly white. The former 
are the ventricular bands (p), while the latter are the vocal 
cords (v). In deep breathing, a triangular opening is seen 
between the vocal cords, through which we can see into the 
inferior cav^ity of the larynx and view the anterior part of 
the cricoid cartilage as well as some of the tracheal rings 
below it (w, p). In some cases two dark circles can be seen 
in the depth of the trachea, indicating the openings of the 
bronchi (b). During tone-production the opening between 
the vocal cords is narrowed to a slit, and this space is called 
the rima glottidis or glottis (chink of the glottis). At the 
termination of the vocal cords we see the arytenoid carti- 
lages, with the interarytenoid space or commissure between 
them. From each side of this commissure a fold, called the 
ary epiglottic fold, extends forward to join the arch of the 



30 DISEASES OF THE NOSE, THROAT, AND EAR 



epiglottis. Upon each of these folds we see two nodules — 
the cartilages of Wrisberg (w) and these of Santorini 
(s). These latter surmount the arytenoid cartilages. 
Attaching the epiglottis to the tongue is seen in the mirror 
a light-colored band — the glosso-epiglottic fold. On each 
side are two grooves, called the glosso-epiglottic fossae. 
The color of the mucous membrane, as seen in the laryngeal 
image, varies from the pearly whiteness of the vocal cords to 




Fig. i6.— Tongue-depressor for phar- 
yngoscopy and direct laryngotracheos- 
copy. Side-view and surface-view of 
the anterior portion. In some cases an 
instrument with a larger curve of the 
anterior portion is more practicable 
(Kirstein). 




Fig. 17. — Displacement of tongue 
in autoscopy ; L, Larynx ; CZ, nor- 
mal position of tongue; CO, posi- 
tion of tongue in autoscopy (Kir- 
stein). 



the reddish yellow of the epiglottis and the pink red seen in 
other localities. There is also considerable variations of 
color, within the limits of health, in different individuals, and 
even in the same individual under different conditions. As 
seen by artificial light it is always redder in color than when 
seen by means of direct sunlight. 

Autoscopy of the larynx and trachea is a name given by its 
discoverer, Kirstein of Berlin, to a method of direct inspec- 
tion of the living larynx and trachea by means of a special 
tongue-depressor (Fig. 16), by which the tongue can be 



THE LARYNGOSCOPE 



31 



as pushed clowinvard, as sliown 



in 



drawn forward as wc 
Fig. 17. 

The patient should bend the upper part of his body 
slightly forward, as shown in Fig. 18. Vox purposes of 
examination it is sometimes desirable that the patient remove 
his collar, especially if it be tight fitting. False teeth should 
always be removed. The observer stands in front of the 
patient, who is seated, and throws light from the reflector 
into the patient's open mouth. The tongue-depressor is 
grasped in the left hand in such a manner that its tip catches 




Fig. 18. — Position for autoscopy. This drawing was made from a partly stripped patient in 
order to show distinctly the position of head and neck during examination (Kirstein). 



m 



the 



between the 



tongue 



and epiglottis, bein< 



careful not to rest the tongue-depressor on the anterior por- 
tions of the tongue. The base of the tongue is now drawn 
evenly and steadily downward and forward as far as possible 
without exercising any force. If these maneuvers are suc- 
cessful, the arytenoids are first brought into view and, finally, 
the whole interior of the larynx and a portion of the pos- 
terior wall of the trachea. In this respect the method con- 



32 DISEASES OF THE NOSE, THROAT, AND EAR 

trasts with the use of a laryngeal mirror, in which, if the 
trachea is seen at all, it is a portion of its anterior wall. 

Even in the hands of an expert, autoscopy, as described 
by Kirstein, yields satisfactory results in only a compara- 
tively few adults and seldom in children. However, the 




Fig. 19. — Types of instruments for autoscopic operations (Kirstein). 



student should practise the method until he becomes expert, 
and should be careful to exercise sufficient discretion and 
gentleness to rarely if ever cause pain, Kirstein states : 
" The autoscope is an instrument in using which the phys- 
ician can hurt cveij patient, but should hurt none." 



RHINOSCOPY 33 

Advantages of Autoscopy of Larynx and Trachea. — Vc^x 
purposes of examination autoscopy possesses rarely any ad- 
vantage over laryngoscopy, although )'ielcling a somewhat 
better view of the posterior wall of the larynx and trachea; 
but for those who have already familiarized themselves with 
the use of the mirror, the method seems more difficult and 
awkward. For the removal of tumors and foreign bodies 
from the posterior wall of the larynx or pharynx the method 
has great advantages, as straight instruments can be used 
under the direct guidance of the eye ; but the anterior wall 
of the larynx and even the posterior surface of the epiglottis 
is rarely brought into view as well by autoscopy as by the 
use of a mirror. Fig. 19 shows the instruments that have 
been employed in autoscopy for the removal of tumors, 
foreign bodies, etc., from the larynx. 

RHINOSCOPY 

Rhinoscopy is the art of inspecting the nasal cavities, and 
may be divided into anterior and posterior rhinoscopy. 
Anterior rhinoscopy is the inspection of the anterior nares 
through the nostrils, and posterior rhinoscopy is the inspec- 
tion of the vault of the pharynx and of the posterior nares 
from behind. 

The word nares should be applied solely to the anterior 
and posterior openings of the nasal cavities. The posterior 
openings are sometimes called the clioaiue. 

The postnasal space or nasopharynx is the cavity bounded 
in front by the posterior nares or choan^e, above by the 
vault of the pharynx, behind by the pharyngeal wall, and 
below by the soft palate. Is is frequently termed the 
nasopJiarynx. 

Technic of Rhinoscopy. — The simplest method of inspec- 
tion is to raise the tip of the nose with a finger, and draw 
the ala away from the septum by means of a bent probe. 
If now the patient's head is tilted somewhat backward, so 
that a strong light from a window or other source of illumina- 
tion can enter the dilated nostril, the nasal cavity will be 
illuminated for a considerable distance, and the condition of 
its lining mucous membrane may be inspected. This was 



34 DISEASES OE THE NOSE, THROAT, AND EAR 



the method commonly employed previous to the invention 
of the forehead reflector. The opening of the nostril may, 
however, be effected more conveniently by means of an 
instrument called a nasal spccidiiin, of which there are a 
great variety for sale in the instrument stores. Of these 
one of the most popular is Myles' spcciihun (Fig. 20). It 

has the advantage that its solid 
blades push the hairs of the vesti- 
bule to one side so that they do 
not interfere with the view. It is 
" self retaining " to a considerable 
extent, which is a decided advan- 
tage. It is not self retaining, 
however, to anywhere near the 
same degree as the instrument 
shown in Fig. 21, which in most 
noses cannot be displaced by 
facial contortions of the patient. 
He has to use his hand in order to 
remove it from his nose. It is 
sometimes necessary, however, to snip away the vibrissae 
before an operation in order to obtain a better view of the 
interior of the nose. This occupies but a moment and is a 
matter of little consequence. 




Fig. 20. — Myles' nasal 
speculum. 




Fig. 21. — Gleason's nasal speculum. 



The idea of devising a speculum was given the author by 
Dr. L. L. Palmer of Toronto, who, while visiting Philadel- 
phia, showed an eye speculum which he had bent in such a 
manner as to serve an admirable purpose as a nasal speculum. 
Two sizes of the instrument should be at hand, and the 
spring of the instrument should be adjusted by bending 
until it does not cause sufficient pressure to occasion the 



RHINOSCOPY 35 

patient pain or annoyance. The instrument is introduced 
by directiu!^ its blades along the floor of the nose until they 
have nearly disappeared within the nasal chamber, when the 
instrument is turned upward until it assumes the position 
shown in Fi^^. 22. It is probably the best " operation spec- 
ulum." Allen's speculum or that of Myles is better for 
inspecting the nasal fossa:. 

Most nasal specula tend to expose the parts in a dis- 
torted condition, and thus deceive the observer as to the 
amount of breathing space that exists in the anterior nares. 
Harrison Allen's hard-rubber nasal specula, as they do not 




Fig. 22. — Gleason's self-retaining nasal speculum in position. 

dilate the nostrils so widely, enable the observer to judge 
of the amount of obstruction to nasal respiration produced 
by a deviated septum or anterior hypertrophy much more 
accurately than he could do with a dilator ; and a nest of 
these instruments should always be at hand to be used in 
such examinations (Fig. 23). When using a nasal spec- 
ulum the instrument and patient's head should be moved in 
such a way that the different parts of the interior of the 
nose are successively brought into view. Any secretions 
that obstruct the view should be removed by means of 



36 DISEASES OF THE NOSE, THROAT, AND EAR 

the atomizer or forceps, or wiped away with cotton wrapped 
on the end of an apphcator ; and any change in the bulk 
of the parts should be tested with the probe, in order to 
determine its density. If an anterior hypertrophy obstructs 
the view of deeper structures, cocain solution should be 
applied to reduce its size and allow light to penetrate into 
the deeper parts of the interior of the nose. 

The first structure brought into view by anterior rhinos- 
copy is the vestibule, in which are seen a number of coarse 
hairs called vibrissae, while a fold of skin or mucous mem- 
brane lies between the vestibule and the inferior meatus. 
To the inner side is the septum and to the outer side the 
inferior turbinated bone, forming the roof of the inferior 
meatus. Above the inferior turbinated bone is the middle 
meatus, roofed in above, except for the olfactory slit, by 
the middle turbinated bone. Through the olfactory slit in 
some individuals a portion of the superior turbinated bone 
may be seen. 




Fig. 23. — Allen's nasal specula. 

Posterior rhinoscopy is to all intents and purposes the same 
process as laryngoscopy, except that a smaller mirror must 
generally be used, the reflecting face of which is turned 
upward instead of downward. The tongue, also, instead of 
being drawn forward with a napkin, is held down by means 
of a tong'ue-depressor. The relative position of patient and 
obser\'er is the same as in laryngoscopy, except that the 
patient's head is not bent backward, but is either held per- 
pendicularly or is inclined slightly forward. The rhinoscopic 
mirror, having been warmed, should be introduced into the 
pharyngeal cavity behind the velum palati, and so placed as 
to reflect the light upward and forward into the vault of the 
pharynx and into the posterior nares (Fig. 24). For this 



RHINOSCOPY 



37 



purpose a No. i, o, oo mirror is generally most useful, but 
a larger mirror can sometimes be used to advantage, and 
should always be employed when the space between the 
palate and pharynx is sufficient to permit it. Posterior 
rhinoscopy is much more difficult than laryngoscopy ; but, 
except in the case of young children, patience and dexterity 
will almost always enable the observer to obtain a glimpse 




'jaiAT. 



Fig. 24. — Course of light rays in posterior rhinoscopy. Sagittal section of head (Sahli). 

of the various parts of the posterior nares and vault of the 
pharynx without the use of accessory instruments. When 
disease of these structures exists or posterior hypertrophies or 
other neoplasms are present, the examination is usually easy 
because of their interference with the motion of the palate 



38 DISEASES OF THE NOSE, THROAT, AND EAR 

and the relatively wider space between the palate and pos- 
terior pharyngeal wall. 

Obstacles to Posterior Rhiiwscopy. — In many cases the 
palate will rise forcibly as soon as the mirror has been intro- 
duced, thus completely shutting off the view of the parts 
above. This difficulty can often be overcome by requesting 
the patient to breathe through his nose, or emit a nasal 
sound like that of the French letter n, or say ''One." Some 
operators ask their patients to " smell," that is, to draw the 
breath inward forcibly through the nose as if endeavoring 
to perceive an odor. 

The observer should in all cases avoid touching the back 
of the tongue or pharyngeal wall, as otherwise gagging and 
retching immediately occur, and further examination is 
rendered futile. 

Occasionally a palate retractor will be convenient. Prob- 
ably the best of these instruments is that of White (Fig. 
25). The wire hook of the instrument is passed behind the 




Fig. 25. — White's palate retractor. 

soft palate, and by pulling the stem gently outward the uvula 
and palate are pulled into the desired position and held for- 
ward by the pressure of the wire loops, which are slid along 
the stem until they rest within the nose. 

Posterior Rhinoscopic Image. — Except in cases of cleft 
palate, it is impossible to obtain a complete posterior rhino- 
scopic image, such as is shown in Fig. 26, but by varying the 
position of the mirror, the different parts may be brought 
into view and studied one after the other. Usually the 
first object seen is a triangular plate, with its apex down- 
ward — the posterior margin of the nasal septum. Above it 
is a mass of glandular tissue called the pharyngeal tonsil, 
while at each side lower down are the crater-like orifices of 
the Eustachian tube. In front of these, and projecting 



OTOSCOPY 



39 



toward the septum, arc the posterior aspects of the tur- 
binated bones. The middle turbinated bone is usually first 
brought into view, and rarely the dim outline of the superior 
turbinated bone may be distinguished above and in front of 




Fig. 26. — Normal picture in posterior rhinoscopy. Diagrammatic in that to obtain 
complete picture the position of mirror must be repeatedly changed: 5". «., Septum ; Lit., 
choana ; P.m., soft palate ; U., uvula ; C.i., lower turbinate bone ; Cm., middle turbin- 
ate bone ; 6'..?., upper turbinate bone; beneath each turbinated the corresponding^ fossa ; 
O.R., roo{ of pharynx; T., opening- of Eustachian tube; \V., promontory of tube; R., 
Rosenmiiller's fossa. (After Schnitzler.) 

it. Below the middle turbinated bone the upper part of the 
inferior turbinated bone is readily perceived; but to see the 
lower part of this structure and the floor of the nose requires 
considerable practise in the use of the rhinoscopic mirror. 



OTOSCOPY 

Otoscopy is the art of inspecting the visible parts of the 
ear. Ordinarily these parts are the auricle, the external audi- 
tory meatus, and the outer surface of the membranatympani. 
Deeper portions of the ear are, however, visible when the 
overlying structures are destroyed by disease or are removed 
during an operation. Generally the dim outlines of the 
malleo-incudal joint can be seen through a normal or atro- 
phied drum-head, and occasionally the chorda tympani nerve 
and other structures. 

The name otoscope is often applied to an instrument con- 
sisting of a hollow cylinder to one end of which ear specula 
of various sizes may be adjusted (Fig. 27). The side of the 



40 DISEASES OF THE NOSE, THROAT, AND EAR 

cylinder is fenestrated for the admission of light, which, when 
the instrument is in use, falls upon a perforated mirror set 
at such an angle within the cyhnder that the light is reflected 
from it through the speculum into the ear. The observer 
examines the condition of the parts by looking through the 
perforation in the mirror. An eye-piece containing a lens 
is adjusted to the proximal end of the cylinder to enable the 
observer to obtain a magnified image of the membrana tym- 
pani. This instrument has been modified by the addition of 
miniature electric-light bulbs and in various other ways. 
Although an excellent view of the membrana tympani can 
be obtained by means of this instrument, it has fallen into 




Fig. 27. — Brunton's otoscope. 

comparative disuse, modern otoscopy being generally accom- 
plished by means of a reflector and an ear speculum. 

Otoscopic Reflector. — The reflector generally used to illu- 
minate the auditory canal and its fundus is the same as that 
employed in laryngoscopy and rhinoscopy (Fig. 2). 

The specula used in otoscopy are funnel-shaped instruments 
constructed of hard rubber or metal. Different forms are sold 
under the names of Wild's, Gruber's, Toynbee's, Boucheron's, 
Kramer's, and Politzer's specula. Gruber's specula (Fig. 28) 
are probably the, best for ordinary purposes of otoscopy, 
because a transverse section of their calibre at right angles 
to their long axes more nearly corresponds with a similar 



OTOSCOPY 



41 



section of the external auditory meatus. However, 
l^oucheron's specula {\'\v[,. 29) are better adapted for use 
during- an operation upon the middle ear, and with many 
otologists are favorite specula for purposes of inspection 
and treatment, because their wide proximal rims afford 
greater space for the manipulation of instruments, and a 
firmer grasp to tlic thumb and fingers when the instrument 
is held within the auditory canal. I^^^ir specula are usually 
sold in "nests" of three or four sizes fitting into a case. 
Those constructed of hard rubber are easily broken, and 
th(xse manufactured of German silver and nickel plated are 
necessarily thicker than is desirable ; a thin, solid-silver 





Fig. 28. — Gruber's specula 



Fig. 29. — Boucheron's specula. 



speculum, aside from its expensiveness, being the preferable 
instrument. 

Relative Positions of Patient and Observer in Otoscopy Con- 
ducted with the Reflector and Speculum. — The patient and 
observer may both stand in front of a window or the source 
of artificial light, or both may be seated upon piano stools 
so adjusted that the eye of the observer and the ear of the 
patient are in the same horizontal plane. The ear to be 
examined should be directed toward the observer, and the 
patient's face turned somewhat away from him, because the 
auditory canal generally extends in a direction inward, for- 
ward, and somewhat downward. If the reflector is worn 
upon the forehead, the source of light should be above or 



42 DISEASES OF THE NOSE, THROAT, AND EAR 

to one side of the patient's head, and so placed as to throw 
the auricle into the shadow. The hght concentrator, with 
reflector, shown in Fig. 4, may be used for otoscopy, the 
reflector so adjusted between the observer and patient that 
it will illuminate the fundus of the auditory canal. 

To introduce the speculum the observer should first direct 
the Hght from the reflector upon the orifice of the meatus, 
and then straighten the auditory canal by gently drawing 
the auricle upward, backward, and slightly outward, at the 
same time endeavoring to see the drum-head without the 
use of a speculum. In many instances this can be accom- 
pHshed satisfactorily, especially in negroes, in whom the 
canal is usually straight and large. Under such circum- 
stances the observer should not be in haste to introduce 
the speculum, as it may dislodge and push into the field of 
view a flake of wax or epithehum, which will greatly inter- 
fere with a distinct view of the membrana tympani. The 
auditory canal having been straightened in the manner de- 
scribed and the parts being fully illuminated, the speculum 
is held by its rim with the thumb and finger and gently 
introduced with a slight rotary motion into the auditory 
canal, in such a manner that its long axis exactly corre- 
sponds with that of the canal. The greatest care should 
be exercised in introducing the speculum not to use it as a 
lever in such a manner as to bring its sharp edge in contact 
with the wall of the canal and cause pain; obstruction to 
the progress of the speculum being overcome by moving 
the whole instrument in a direction opposite to that in which 
the obstruction is felt until the membrana is brought into 
view, when the speculum may, if necessary, be retained in 
position by grasping it and the auricle in the manner shown 
in Fig. 30. 

Obstacles to Otoscopy. — The chief obstacle to the beginner 
is caused by so misdirecting the long axis of the ear spec- 
ulum that it does not correspond with the long axis of the 
auditory canal, so that a portion of the auditory canal is 
brought into view or only a portion of the membrana is 
seen. Under such circumstances the end of the speculum 
within the ear should be moved about until a satisfactory 
view of the drum-head has been obtained. Generally it 



OTOSCOPY 



43 



will be found that tlic cause of failure has been that the 
axis of the speculum has been directed too far backward 
and upward. 

Another cause of difficulty is excessive sensibility of the 
auditory canal or swellin^^ of its walls, the result of diffuse 




Fig. 30. — Otoscopy with the reflector and ear speculum. The arrows represent course 

of light. 

inflammation. Sometimes a satisfactory view of its deeper 
parts can be obtained under such circumstances by gentle 
and persistent effort, a small speculum being used to dilate 
the auditory canal. 

Siegle's pneumatic speculum (Fig. 3 1) is an air-tight chamber 
to which specula of various sizes can be attached by means 
of a screw-joint. The side of the air-tight chamber carries 
a perforated knob, over which is slipped a rubber tube 
terminating in a rubber bulb. The proximal end of the 
instrument is glazed either with plane glass or with a convex 
lens set at an angle of 45 degrees with the long axis of the 
instrument. When the instrument is in position within the 
auditory canal, the surgeon is enabled to judge of the 
mobility of the whole or of a part of the membrana tympani 
by observing its movements during condensation and rare- 



44 DISEASES OF THE NOSE, THROAT, AND EAR 

faction of the air in the auditory canal brought about 
by the action of the surgeon's hand upon the rubber bulb. 
Before using the instrument it is well to sHp a short piece 
of wet rubber tubing over the end of the speculum to 
ensure its fitting into the auditory canal as nearly air tight 




Fig. 31. — Siegle's pneumatic specula. 



as possible. When the Eustachian tube is impervious to 
air the pneumatic speculum furnishes the only means of 
determining the mobility of a part or the whole of the 
membrana tympani. 

Instead of using a rubber bulb to produce rarefaction 
and condensation of the air in the auditory canal, a piston- 
syringe may be employed or the masseur 
of Delstanche. This instrument (Fig. 32) 
has a spring inside the barrel by which the 
piston is forced outward. By means of a 
screw the length of the movements of the 
piston and hence the degree of rarefaction 
and condensation of air in the auditory 
canal can be modified to suit individual 
cases. The masseur of Delstanche is a 
useful instrument, but probably of no more 
practical utility than the simple rubber 
bulb when employed by a judicious opera- 
tor, for it should be borne in mind that it is entirely pos- 
sible to rupture some membrana tympani by too vigorous 
use of aural massage. 




Fig. 32.— Masseur of 
Delstanche. 



OTOscurv 



45 



Machines siniikir to Fig. 33, whose motive power is com- 
pressed air, electricity, or a water motor, arc sometimes 
employed. They yield more rapid rarefaction and con- 




FiG- 33- — Aural masseur {Jour, of Laryngol., Rhinol., and OtoL, Jan., 1902), 

densation of the air of the auditory canal than the hand 
bulb and occasionally may prove more useful. 



ACCESSORY INSTRUMENTS 

The laryngeal sound consists of a piece of silver wire, 
rounded at one end and inserted in a universal handle 
(Fig. i). It should be sufficiently long to reach the anterior 
angle of the glottis without bringing the fingers holding the 
handle into the patient's mouth, and thus obstructing the 
view, and sufficiently firm to resist a considerable amount 
of pressure without bending. 

The cotton applicator consists of a piece of aluminum or, 
better, copper or iron wire of about the same size and 
length as the laryngeal probe, with roughened ends ; so 
that a piece of absorbent cotton can be tightly wrapped 
around one end without fear of its becoming loose. This 
tuft of absorbent cotton wuli carry enough solution for any 
application within the laryngeal or postnasal cavities. For 



46 DISEASES OF THE NOSE, THROAT, AND EAR 

applications to the nasal cavities smaller instruments are 
desirable, and Allen's applicator (Fig. 34) is better adapted 
for this purpose. Allen's probe (Fig. 35) consists of a 
conic piece of soft, malleable steel wire fitted into an 
aluminum handle. It is extremely light and dehcate, and 
may be used either for the nose or for the ear. When 
used as a probe, a few fibers of absorbent cotton are 
wrapped about its tip, in order to cover its sharp extremity. 
The tip of the instrument can be bent into the form of a 
hook to bring forward nasal polypi or ascertain their place 



Fig. 34. — Allen's nasal applicator. 

of origin, the thickness of their pedicle, etc., or to probe 
the attic of the tympanum. The presence of exposed bone 
is readily detected by the spicules catching in the cotton 
fibers and imparting a characteristic resistance. It also 
may be used for the application of chromic acid and other 
caustics, w^hich are either fused upon the tip of the probe, 
or the coarsely powdered particles of the caustic may be 
entangled in a few fibers of moist cotton wrapped about the 
tip, and thus safely conveyed to the location within the 
nose where the cauterization is to be made. 



Fig. 35. — Allen's probe. 

The Atomizer. — In most forms of throat and nasal disease 
sprays are extremely useful, not only to cleanse the parts 
and remove accumulated secretions, but also as a means of 
spreading medicated solutions over a large surface. For 
laryngeal and postnasal use and as an atomizer, to fit into 
the rhinologic instrument bag for use in treating patients at 
their homes, the DeVilbiss atomizers are probably the best, 
as they throw a fine spray either upward or downward or 
straight forward. The " Magic atomizers " are, however, 
preferable for washing out the anterior nasal cavities, and as 
a " prescription " atomizer for patients' use. 



OTOSCOPY 



47 



The air-current necessary to produce the spray from 
atomizers may be supplied either by a rubber hand-bulb or 
an air-compressini; apparatus. 

In spraying the nose, pharynx, or larynx with a hand 
atomizer, the bottle of the instrument should be grasped 
between the thumb and first finger of the right hand with 
the rubber bulb in the hollow of the hand. The rub- 
ber bulb can then be pressed by the three remaining fingers 
with sufficient force and rapidity to give a continuous spray. 
This method of employing the atomizer leaves the left hand 



5 6 




Fig. 36. — Atomizer. 



free to elevate the tip of the nose or manipulate a tongue- 
depressor. In spraying the nasal cavities the tip of the nose 
should be elevated with the finger and thumb of the left 
hand, and the end of the atomizer should rest against either 
the thumb or finger of the operator, and not the rim of the 
patient's nose. The use of this method will prevent the 
necessity of sterilizing the end of the atomizer tubes each 
time they are used upon a patient. 

Because secretions tend to gravitate toward the floor of 
the nose, especial attention should be directed toward the 
inferior meatus in washing out the interior of the nose. It 
is a good plan to tip the head of the patient slightly back- 



48 DISEASES OF THE NOSE, THROAT, AND EAR 

ward and direct the spray from the atomizer somewhat down- 
ward, that is, in a direction toward the lobe of the ear. Under 
such circumstances the nasal secretions that have accumu- 
lated on the floor of the nose are readily washed into the 
pharynx and are hawked down and expectorated. The 
stream of the atomizer can then be directed to any por- 
tion oi the upper part of the nose which, on inspection, 
appears covered by semi-inspissated secretions. 

For washing out the postnasal space an atomizer throw- 
ing a spray straight forward through the nose is generally 




Fig. 37.— DeVilbiss atomizer No. 54. One of the tubes is only Jg inch in diameter 
and throws a spray in four opposite directions. It can be easily carried through the nares 
into the pharyngeal vault in the same manner as an Eustachian catheter. The postnasal 
space can be successfully treated, when an atomizer introduced into the throat of a patient 
would cause repeated gagging. It is excellent for washing out or making applications to 
the nasal cavities. It has a tube that may be turned so as to spray the tonsils or carried 
behind the soft palate for making applications direct to the vault of the pharynx and post- 
nasal cavities. This atomizer has no inner tube that is liable to become clogged. 



sufficient ; but in cases where partially dried and glue-like 
secretions are very adherent, the atomizer with a tip turned 
upward answers a useful purpose (Fig. 37). The atomizer's 
tubes are introduced through the mouth behind the soft 
palate, and the patient's head is bent forward over a bowl. 
The spray from the atomizer should be ver}^ coarse and 
applied with considerable force. Under. such circum.stances 
a stream of fluid and mucus flows from the anterior nares 
into the bowl, or the masses of glue-Hke mucus adhering 



OTOSCOPY 



49 



to the pharynx arc dislodi^^cd by the coarse spray, aiul 
afterward hawked down and expectorated. 

However, such masses of mucus are more readily re- 
moved from the pharynx by means of solid streams of fluid 
than by the coarsest spray from an atomizer. Therefore 




Fig. 38. — Syringes with interchangeable nozzles : a. Syringe of ^-dram capacity for 
cleansing and applying solutions to the attic by means of Blake's cannula (2, 3, and 4). 
Also for making applications to the Eustachian tube bj' means of nozzle 7 and an ordinary 
Eustachian catheter. /'. Antitoxin syringe, holding 2^4 drams. May be used with Blake's 
cannula for cleansing middle ear or with postnasal nozzle (i) for cleansing the posterior 
nares. It is convenient where the operator prefers a piston- to a bulb-syringe, c. l)entists' 
tooth syringe, capacity i ounce. This is probably the best syringe for removing impacted 
cerumen and for coarse syringing of the auditory canal. When fitted with a moderately 
large long silver nozzle (4) any of the accessory cavities of the nose that can be probed can 
be washed out through their anatomic orifices. For this purpose the silver nozzle should 
be made of pure silver, so that it can be bent readily to the requisite curve, and the operator 
should be provided with four or five such nozzles about 5 inches long and of the diameter 
of Nos. 3, 5,6, and 8 of the French catheter scale. Instead of these silver nozzles an 
Eustachian catheter may be employed, or the nozzles 5 and 6, fitting on to the nozzle 7, 
which screws on to the syringe when nozzle 8 is unscrewed. It is well for the operator to 
be provided not only with several sizes of the straight cannula (4), but also with several 
sizes of Blake's cannula (2 and 3"), to be used with this syringe or syringe d. 



the syringes (Fig. 38, b or r, with postnasal tip i) for cleans- 
ing the nasopharynx generally are more useful instruments. 
The tip is introduced behind the palate, the patient then 
leans forward over a bowl. The streams or stream of fluid 
is thrown with sufficient force into the postnasal space to 



50 DISEASES OF THE NOSE, THROAT, AND EAR 

dislodge the masses of mucus from the pharynx, and wash 
them forward through the nose into the bowl. 

When an atomizer is prescribed for a patient's use at home, 
the object that the surgeon wishes to accomplish should be 
carefully explained to the patient and he should be instructed 
in the use of the atomizer and also how to keep the instru- 
ment in good order. If this is not done, the patient's use 
of the atomizer at home will amount to practically nothing. 
For example, if an atomizer and a detergent spray, such 
as Dobell's solution, is prescribed with the main object of 
cleansing the nose, the patient should throw his head back 
and point the beak of the atomizer downward (not upward), 
so that the main force of the spray will be directed along 
the floor of the nose into the nasopharynx. It should be 
demonstrated to the patient so that he thoroughly under- 
stands that if while he is using the atomizer he breathes 
gently through his nose the spray will pass downward 
behind the relaxed palate into his mouth and can be expec- 
torated. That, on the contrary, if he holds his breath, the 
fluid will be retained in the nasopharynx upon the contracted 
palate and will run out. of his nose as soon as his head is 
lowered, with the result that the nasopharynx is not as 
efficiently cleansed as would otherwise be the case. 

The interior of the nasal cavities can be cleansed as thor- 
oughly by means of a hand atomizer as by means of an 
atomizer whose spray results from the use of the most 
expensive of air-compressing apparatus ; but the latter are 
convenient, and where a large number of patients are to be 
treated save the surgeon's hand the fatigue that would 
result from long-continued use of the hand atomizer. 

There are a large variety of air compressors for sale in the 
instrument stores, and it is difficult to state which one is the 
most practical and useful. Fig. 39 shows a fairly good 
apparatus for use when the amount of compressed air 
required is by no means great. 

However, the most satisfactory apparatus for furnishing 
compressed air is a water air-pump, such as is used by 
saloon-keepers for forcing beer and ale from the barrels in 
the cellar into the faucets in the bar-room. The water-pump 
is attached to a water-pipe in such a manner that water may 



OTOSCOPY 



51 



run throii<^rh it and How into the waste-pipe or sewer. It is 
automatic and continues in operation until the air-pressure 
in the receiver equals that of the water in the supply pipe. 
The l^uck l<:ye and some other pumps furnish an air-pressure 
double that of the water in the supply pipes, but arc pro- 
portionately slow in tlieir action. The Champion and Little 




Fig. 39.— De Vilbiss' compressed-air atomizing apparatus. 



Wonder (Fig. 40) pumps are rapid and effective instruments 
for furnishing practically an unlimited supply of compressed 
air at the same pressure as the water in the supply pipes. 

As an air receiver, when one of these pumps is used, an 
ornamented copper cylinder maybe placed in the surgeon's 
office; but nothing answers the purpose better than an 
ordinary galvanized wrought-iron cylinder or "boiler," such 
as is found in most American kitchens, as a reservoir 
for hot water as a part of the so-called " circulating 
boiler" apparatus for supplying hot water for domestic pur- 



52 DISEASES OF THE NOSE.. THROAT, AND EAR 

poses. The water air-pump may be attached to the water 
pipes underneath the sink in the physician's office, and the 
air receiver placed down cellar, or both pump and air 
receiver may be placed in the cellar should the plumbing 
permit of such an arrangement. Whatever the position of 
the air receiver, a pipe or tube should lead from it to a stop- 



AIROUTLLT 



AIR INLET 




WATER 
OUTLET 



Fig. 40. — The Little Wonder pump 



cock upon the wall, immediately at the side of or beneath 
the adjustable gas bracket (Fig. 41). Attached to the stop- 
cock there should be a rubber tube three or four feet in 
length, terminating in an automatic cut-off (Fig. 42). When 
compressed air is used for other purposes than supplying an 
air-current for atomizers, the pipe from the air receiver should 




Fig. 41. — Six stopcocks on oil-finished walnut board, to connect with air receiver by 
tubing with stopcock A. In this way various atomizers or medications can be readily used 
It is made to fasten on wall by screws. 

terminate in a bracket of stopcocks from which rubber tubes 
lead to the nebulizer, the aural masseur, etc. The automatic 
cut-off is an instrument by which compressed air is con- 
veniently supplied to an atomizer. The end of the instru- 
ment {d) is attached to the rubber tubing of the compressed- 
air apparatus, and the nozzle (U) of the instrument inserted 



OTOSCOPY 



5. 



into tlie hole in tlic nipple of the atomizer 
hand-bulb previously 
down the lever {c) a 



through the atomizer 



from uhieh the 
has been removed, and by pressing 
current of compressed air is forced 
in the same manner as if a rubber 
The current of air ceases as soon as 
In using the automatic cut-off. the 




Fig. 42. — Boekel's automatic cut-off. 



hand-bulb were used 

the lever is released 

atomizer is held in the right hand 

and the lever of the automatic 

cut-off pressed downward by the 

thumb. 

Sinks. — A most convenient ad- 
junct to a laryngologist's office 
is a sink. It should be supplied 
with hot and cold water. There 
have been a number of sinks 
manufactured for the use of phys- 
icians and hospitals. The best of 
these are constructed of white 
enameled iron, and the flow from 

the spigot is controlled by foot levers. This arrangement 
prevents the necessity of turning off the water with the 
hands after they are washed. 

A swinging spittoon may be attached to the sink or wall 
in such a manner that it can be swung out of sight when 
not in use. A water spittoon such as is employed by dentists 
is not more convenient but certainly looks better than even 
the most ornamental receptacle for expectorations, and 
although bulky adds somewhat to the appearance of care 
and neatness about the office. 

Pynchon's cabinet (Fig. 43), for instruments, linen, etc., is a 
convenient office accessory. It is provided with 18 drawers 
of different sizes (each partitioned to accommodate regular and 
special instruments) and compartments for clean and soiled 
linen, that for the latter having ventilators in both front and 
back. The clean linen compartment has a glass shelf and 
bev^eled plate-glass door. In addition to these there is a 
compartment provided with a swinging glass tray which, 
when fully drawn out, discloses another drawer. 

The nebulizer (Fig. 44) is indispensable because vapors 
will penetrate where fluids and the spray from an atomizer 



54 DISEASES OF THE NOSE, THROAT, AND EAR 

will not. These instruments, therefore, are useful in the treat- 
ment of diseases of the middle ear and the accessory cavities 
of the nose and the smaller bronchial tubes. 

Nebulizers are manufactured in many styles, from the 
single nebulizer, for patients' use at home, to more elaborate 
instruments for office use, like that shown in Fig. 44, which 
consists of a number of nebuHzers connected together in 
such a manner that one or more can be utilized at a time. 
The vapor from each vaporizer when in use passes through 




Fig. 43. — Pynchon's cabinet 



the mixing bottle shown in the center of the cut, and when 
two or more vaporizers are used at the same time their 
combined product is blended in the mixing bottle before 
being inhaled by the patient. A valve ( V, Fig. 44), worked 
by the thumb or finger in the same manner as the automatic 
cut-off, permits inflation of the middle ears and accessory 
nasal cavities, and by rapidly moving this valve successive 
jets of vapor, as it were, may be thrown into these cavities, 
massaging the mucous membrane of the accessory cavities 
and the intratympanic structures. When used for this 



o rosea PY 



55 



purpose, the nose-piece of the instrument is inserted intotl.e 
patient's nose and he is told to puff out his cheeks. Puff- 
inf^ out the cheeks causes the soft palate to rise, and shuts 
off communication between the nose and nasopharynx with 
the rest of the respiratory tract. If now the valve V be 
pressed upon by the fini^rcr, the nebulized vapors enter the 
nose, its accessory cavities, and the middle ear. By rapidly 
working the valve V, the pressure of the vapor within these 
cavities is alternately increased and decreased and the 
mucous membrane massaged. Excessive pressure within 



Current JnUrruP'"l$ l''-'"'- ^ 
,.u ,- ... '' ^/''< '' 




Six-flask Globe multinebulizer. 



the middle ear can be prevented by the patient stopping 
his auditory canals w^ith the finger-tips. 

Inhalers are mostly employed for the inhalation of the 
vapors of a drug suspended in hot water. The simplest 
form of this instrument is the bottle-inhaler, to be found 
for sale in most drug-stores. It consists, in its simplest 
form, of a wide-mouthed bottle, through the cork of which 
two glass tubes are thrust. One reaches nearly to the 
bottom of the bottle ; the other passes simply through the 
cork, and is bent at the upper extremity. The bottle is 
filled one-third full of a solution, and the patient, by inhaling 
through the bent glass tube, causes air to bubble through 



$6 DISEASES OF THE NOSE, THROAT, AND EAR 

the fluid and become impregnated with the volatile sub- 
stances in the fluid before being drawn into the lungs. 
Compound tincture of benzoin (i teaspoonful to the inhal- 
ing bottle one-third full of hot water) is a domestic remedy 
of considerable reputation and some value in inflammation 
of the upper respiratory tract. 

The Powder-blower. — Remedies are often applied to the 
interior of the nose and larynx in the form of an impal- 
pable powder. For this purpose the instruments shown in 




Fig. 45. — Davidson's reservoir powder-blower. The instrument is also made with a 

curved tip. 

Figs. 45 and 46 will be found useful. The reservoir 
insufflators of DeVilbiss and Davidson are very convenient 
instruments, which obviates the necessity of loading the 
powder-blower each time that it is used. However, they 
have the disadvantage of sometimes becoming temporarily 




Powder-blower. 



clogged, and at the next attempt to use them discharge a 
much larger quantity of powder than is required into the 
patient's air-passages. Sometimes a very large amount of 
powder will be unexpectedly thrown into a patient's larynx 
from this instrument, causing momentarily great distress and 
severe laryngeal spasm, which, however, quickly subsides if 
the patient is given a glass of water to drink and told to hold 
his breath for a moment. Such accidents can, however, be 
avoided by care on the part of the operator. 



OTOSCOPY 



57 



The Hot-air Apparatus. — J lot air is occasionally beneficial 
ill the treattnent of diseases of the upper respirattjry tract 
and middle ear. It allays the swelliui^ and irritation and 
decreases the blood-pressure. It is especially useful in 
acute inflammatory diseases of the accessory sinuses and 
middle ear, althoui^h the relief is often more transient than 




Fig. 47.— Van Sant's hot-air apparatus. 

permanent. An effective method of appHcation is the hot 
room of a Turkish bath. The modification of an apparatus 
used by dentists for drying tooth cavities (Fig. 47) or more 
elaborate apparatus, in which air is heated by an electric 
current, are occasionally useful, as they permit a continuous 
current of hot air to be thrown on inflamed tissue in any 




Fig. 48. — Soft-rubber eye, ear, and ulcer syringe. 

portion of the mouth, nose, or auditory canal. Sometimes 
it affords at least temporary relief from the pain and tinnitus 
of acute middle-ear catarrh. The apparatus shown consists 
of a cylinder of brass in which is enclosed a piece of gas 
carbon, and so constructed that it fits into a handle. The 
cylinder is heated over a Bunsen burner and the automatic 



58 DISEASES OF THE NOSE, 

cut-off attached to the handle. Air passing through the 
apparatus from the cut-off is heated as it passes around the 
gas carbon, and may be conveyed to the desired locality of 
the patient's nose, throat, or ear by means of one of a set 
of detachable end-pieces. 

For the patient's use at home the eye, ear, and ulcer 
syringe of the Davidson Rubber Co., made of one piece of 
soft rubber (Fig. 48), answers a useful purpose for syringing 
the nose or for the aurist's use in syringing mastoid wounds. 
The nozzle of the syringe is made of soft rubber, and hence 
it can be inserted in the auditory canal or a mastoid 
wound without danger or pain. 

STERILIZATION OF INSTRUMENTS 

All instruments used in operations upon the nose, throat, 
or ear should be carefully sterilized by boiling in a 5 per 
cent, bicarbonate of sodium solution. After an operation 
the instruments are placed in a tray and soaked for five 
minutes in order to dissolve the dried blood adhering to 
them. Hot water should not be used for this purpose, as 
it coagulates the albumin of the blood and renders it more 
difficult to remove. The instruments are then scrubbed 
with hot water and soap. If they need polishing, sapolio or 
a fine sand-soap should be used. They are then boiled for 
five minutes in a 5 per cent, solution of sodium bicarbonate 
and rapidly dried while still hot in order to prevent rusting. 

For the rapid drying of larger instruments, wiping with a 
sterile towel while the instruments are still hot answers 
every purpose. For smaller instruments and those with 
delicate joints — cannula, snares, etc. — it is better after boil- 
ing to wipe them with a towel and then immerse them in 95 
per cent, alcohol for a minute or two. They should then be 
carefully wiped with a towel, so that every particle of moist- 
ure is removed by the wiping and the evaporation of the 
alcohol. 

Instruments for examination and treatment, such as tongue- 
depressors, specula, probes, applicators, etc., are used so 
frequently during the office hours or in dispensary work that 
(unless the surgeon possesses a large stock of these articles 



STER /LIZ AT/ON OF INSTRUMENTS 59 

that can he boiled at the bci^inniiii^ of the hour in sufficieiit 
numbers to furnish each patient a special instrument witlunit 
exhausting the supply) they are best sterilized by burning 
with wood alcohol. This method has the advantage that it 
takes but a moment and can be done in the presence of the 
patient, who is thus assured beyond peradventure that only 
sterile instruments have been used in the diagnosis and 
treatment of his case. 

The operator should be provided with two white enameled 
steel trays. Into the first of these should be placed instru- 
ments for the examination and treatment of a patient. 
Over the instruments should then be distributed a teaspoon- 
ful or two of wood alcohol, which is then lighted with a 




Fig. 49. — Sterilizing instruments by flaming with alcohol. 

match. The flame lasts but for a moment, but the instru- 
ments are heated far above the temperature of boiling water 
and are, of course, rendered absolutely sterile. 

Small instruments treated in this manner cool almost as 
rapidly as they are heated. Larger instruments, like tongue- 
depressors, retain their heat for an inconvenient time, and it 
may be necessary to cool them by dipping them in water, 
spraying them with an atomizer containing an alkaline wash, 
or pouring a little grain alcohol over them. As the instru- 
ments are used they are placed in the second tray, and are 
sterilized in the same manner before being again employed. 

The disadvantages of the method are that it cannot be 
used for small aluminum instruments or those soldered with 
soft solder and that it soon tarnishes the instruments. 

Syringes, soft-rubber tubes, hard-rubber nozzles, and 



6o DISEASES OE THE NOSE, THROAT, AND EAR 

glass instruments are best sterilized by soaking them for 
five or ten minutes in a 5 per cent, aqueous solution of for- 
malin (40-volume aqueous solution of formaldehyd gas). 
The barrel of the syringe should be filled with the solution 
and the entire syringe immersed. If the syringe is sterilized 
in this manner immediately before being required it should 
be carefully rinsed in sterile water before being used to pre- 
vent the irritating effects of formalin, for it should be borne 
in mind that even very dilute solutions of formaldehyd gas 
are very irritating to the mucous membranes of the nose, 
throat, or middle ear. 

Atomizers should be used in the manner previously de- 
scribed, so that the tips never come into actual contact with 
the patient on whom they are used. When made with inter- 
changeable tips the extra tips may, of course, be kept in an 
antiseptic solution, that of formaldehyd being perhaps the 
most reHable. 

Although boihng in sodium bicarbonate solution and the 
other methods of disinfection described above are reliable, 
it is advisable for psychologic reasons at least to have a special 
set of instruments for syphihtics and another special set for 
those with tuberculosis. 

Preparation of Operator. — Before operating on the nose 
or throat the surgeon should prepare himself, as for any 
other operation, by scrubbing his hands and arms with green 
soap, rinsing in alcohol, and immersing his hands in bichlo- 
rid solution, or prepare himself by any other method he 
has found satisfactory^ 

Sterilization of Nose. — Unfortunately we do not possess a 
reliable antiseptic for sterilizing the nose or nasopharynx. 
Any solution of carbolic acid (probably the most sedative to 
mucous membranes of the common antiseptics) strong 
enough to kill bacteria w^ould excite a local inflammation 
that would interfere greatly with the rapid healing of the 
operative wound. The same remark applies in still greater 
degree to the other antiseptics. However, before an opera- 
tion the mucus membrane should be freed, especially in 
atrophic cases, from adherent mucus by an alkaline spray 
or, if this is not sufficient, an alkaline spray to which per- 
oxid of hydrogen has been added. 



EXAMINATION OF PAI'IKNI'S 6l 

EXAMINATION OF PATIENTS 

First listen passively to the patient's story of his ilhiess ; 
asking judicious but not leading questions, so as to elicit the 
facts of the case, such as the influence of his employment 
upon his health or any inherited tendency that he may have 
toward disease of the nose, throat, or ears, cause of the 
disease, the length of time that it has continued, and the 
symptoms other than disease of the nose, throat, or ears that 
may be present. In questioning the patient the physician 
should bear in mind the effects of " suggestion " upon patients 
of nervous temperament as regards tinnitus. Many neurotics 
with disease of the middle ear will experience for the first 
time subjective noises in their ears upon being asked lead- 
ing questions in regard to tinnitus, and afterward complain 
of the presence of this symptom, which previous to that 
time had not attracted their attention. 

Careful notes of the patient's history should be made in 
the case-book, and especial prominence be given to the 
symptoms of the disease from which he seeks relief. 

Examine the tongue, as to whether coated or clean, pale 
or flabby, or of a natural color and resistance; look for 
ulcerations or mucous patches upon the tongue or the in- 
side of the mouth ; and also notice the shape and condition 
of the teeth. Having depressed the tongue, observe the 
palate and uvula, the anterior pillars and tonsils, the posterior 
pillars and posterior pharyngeal wall. Notice any change 
from the natural color, shape, or mobility of the parts, the 
presence or absence of foreign bodies or hardened secre- 
tions. 

The nose should next be examined by anterior and 
posterior rhinoscopy and, finally, the laryngeal mirror 
should be introduced. In these examinations, notice the 
condition of the parts in the following order, viz. : (i) Color 
and condition of the mucous membrane ; (2) size and shape 
of the part examined; (3) loss of substance by ulcers, etc.; 
(4) presence of foreign bodies, neoplasms, or accumulated 
secretions; (5) mobility of the parts and functional disturb- 
ances. During the examination touch any suspicious 
swelling with the probe, so as to ascertain its mobility, and 



62 DISEASES OF THE NOSE, THROAT, AND EAR 

whether it is composed ■ of bone, cartilage, or softer 
structures. As the examination progresses, the resuh 
should be jotted down in the case-book, and any deviation 
from the normal in size or shape, or the presence of neo- 
plasms or foreign bodies, sketched upon the margin of the 
page. ; 

In cases complaining of aural disease the hearing should 
next carefully be tested by the voice, the watch, and the 
tuning-fork. In making a record of the results of the tests 
for hearing it is convenient, to facilitate easy reference at a 
subsequent period, to devote one or more lines in the note- 
book to each ear, using abbreviations to economize space ; 
for example, as follows : 

A. D. 

DexS'or ^- V.=whisper, 3 ft. W. = i-|. T.-F. Co, vertex bestin A. S. M.=§g. M. A. 1%. 

(Hear- (Voice). (Watch). (Tuning-fork). (Mastoid). (Meatus 

R. E. ing). Auditorius). 

(Right Ear). 

A. S. 

stnSor H. V. = L.C.6ft. W.=^||. T.-F. Co. M.=|§. M.A.fg. 

(Hearing). (Voice). (Loud Con- (Watch). (Tuning- (Mastoid). (Meatus 

L. E. versation). fork). Auditorius)- 
(Left Ear). 

In the above record of the tests of the hearing power 
it will be noticed that bone-conduction, as tested by a c^ 
fork, is somewhat impaired for the right ear and apparently 
increased for the left, indicating, as previously explained, 
that there exists in the right ear not only disease of the 
conducting apparatus, but also impairment of the receptive 
apparatus. For most cases one tuning-fork, preferably a 
large Cg fork, is all that is required ; but for reasons 
previously stated the aurist should be provided with at least 
five forks — C, c, C2, C3, c^ — which should all be used in 
testing the hearing in certain cases apparently demanding 
operative interference, in order to ascertain the probable 
result upon the hearing. 

After the hearing has been tested the aurist should 
inspect the parts of the ears made visible by means of 
otoscopy, carefully noting the condition of the external 
auditory canal and drum-head ; and if the membrane be 
wholly or partly destroyed as the result of disease or 



L 



DR. F. ROHRER'S (ZURICH) DIAGNOSTIC TABLE OF DISEASES OF THE EAR. 



Name: 
Age:.. 



Occupation : 
Residence:... 



Diagnosis : 



Days 

Weeks 

Years 

Since childhood 

Congenital 



Origin 
obable ( 



and Probable Oause. 



Gradually;'"®' 
Cold 
Coryza 
Infectious Diseases 



Otorrhcea. 



Formerly had 
Present since 
Absent 




Subjective Sounds. 



Formerly had 

Weak 

Intense 

Intermittent 

Continuous 



Autophonii 
Pulsation 
Rustling 



Whistling 
Chirping 
Rin^n/ 
Humming 
Buzzing 



Musicaftones Hears voices 



Weeks 

Years 

Since childhood 

Congenital 



Gradually }»"«' 
Cold 
Coryza 
Infectious Diseases 



Formerly bad 
Present siuce 
Absent 



Formerly had 

Weak 

Intense 

Intermittent 

Continuous 



Pulsation 

Rustling 

Rushing 

Boiling 

Singing 

Bustling 



Whistling 
Chirping 
Ringing 



Father n™„^f».l.or / Fa'l>er Cousin (F). 

Mother Grandfather | Mother Cousin (M), 

Brother r'..„„^.„„n,.r J ^*"'^'' Uncle. 

Sister <^'^*"<'""'"'*'^1 Mother Aunt. 



Constitution ; Phthisis. 

Scrofulous : Acute artic. rheumatism. 

Syphilis: 

Alcoholic : 

Defluvium capillorum: 



{frontal, 
occipital, 
temporal. 



Vertigo 



Revolving Convulsions. 
Swaying Oppressive feeling. 



Naso-pharyngeal Space. 
Coryza : Ozn-na. 

Pharyngitis : Tonsillitis hypertr. 

Adenoid Vegetation : Aprosexia. 
Mouth-breathing : 
Snoring : 



Hears better in a Noi 
Paracusis of Wlllla 



absent, 
present. 



Mense.s Leucorrha-a Abortion 

Pregnancies Chronic Metritis 



111 



. I Bone conduction: 
«i I Diminished 

►2 SL^'PFl"'"' 



Air conduction ; 
Diminished 
Disappeared 
Negative 



Air conduction: 
Diminished 
Disappeared 
Negative 



^ ( For Patulous 

"« i normal 

" ( narrow 

^ f For Patulous 

.2P .j normal 

cS ( narrow 



Smoker. 
SnufTer. 



Tympanum. 



Hearing Distance 
before after the first Air-douche. 



Bone Conductions 

on Mastoid Process. 

Politzer Tuning-fork 



Hearing. 



Normal 
Wide 
Narrow 
Cerumen 



Lustre 



Slegle.^ normally 



Light cone 

Color 

Hammer handle 

Curvature 



Polllzer 



Always the same since : 
Rapidly decreasing: 
Slowly becoming worse : 
Fluctuations : 



Normal 
Wide 



Lustre 



(adherent 
)< normally- 
(. movable 



Light cone 
Cerumen j Color 
Eczema Hammer hf 
Pus Curvature 



Absent 
Weak 
Good 



Nostrils. 



Absent 
Weak 
Good 



I'ft 


ri,h, 


Normal 


Normal 


Narrow 


Narrow 


Impassable 





Vibration Bone conduction Air conduction 



• Vibration Bone conduction Air conduction 



tl. 



{J J Sclerosis 

J I Pain from Pres. 



I Sclerosis 
Pain from Pres. 



^ rNaevi 

be "j Helix Lumps or Projections 
A y Eczema 



»4000 56000 42000 33G00 28000 24000 '. 



Soimding vibration per Sec. 



WOOO 56000 42000 33600 28000 24000 21000 18856 16800 15273 14000 1 



Vibration per Sec. 6.5536 < 



Former Treatment: 



Therapeutics : 



Politzer's Method. 
Catheterization. 
Rarefaction. 
Probe Pressure. 



Tubal Massage. 
Injection in Meatus. 
Galvano-puncture. 
Galvanization. 



lodo-ethyl. 
Amyl nitrite. 
F'yrldin. 

Cociiine-atropine. 
Alcohol. 



Boric acid. 

Iodoform. 

lodol. 

Alumin. acid. tart. 

Unguent, jod. 



Pilocarpine. 
Acid, hydrobrom. 
Ferrum jod. 
Kali jod. 
01. jecor. aselli. 



After the hearing has been tested the aurist should 
inspect the parts of the ears made visible by means of 
otoscopy, carefully noting the condition of the external 
auditory canal and drum-head ; and if the membrane be 
wholly or partly destroyed as the result of disease or 



EXAMINATION OF PATIENTS 63 

accident, noting; the condition of the nuicoiis nicinljranc of 
the tympanum and other structures that may be visible. 
In most instances it is advisable to make a diagram or rude 
drawing of tlie condition of the tympanum, and in making 
notes as to the results of otoscopy to give one or more 
separate lines in the note-book in the same manner as when 
recording the results of the tests for hearing. 

The patency of the Eustachian tubes should next be 
tested by means of the Politzcr method and the aural 
stethoscope or, if necessary, the Eustachian catheter should 
be used. 

In many cases it is neither necessary nor desirable to 
make as elaborate an examination as that described above. 
Dr. Rohrer's diagnostic table, here inserted, although too 
elaborate for daily use, will be found convenient for refer- 
ence, and from it as a model a less complicated page may 
be constructed if the physician desires something of the 
kind on which to keep notes of his cases. The writer, 
however, after using for some years a somewhat elaborate 
record book, now uses a card-index, with simple plain 
cards, for his case records. 



THE NOSE 

ANATOMY OF THE NOSE 

The external nose is an arch-shaped framework, bony 
above and cartilaginous below, covered by integument 
externally and lined within by mucous membrane. It is 
separated into two portions, practically two noses, by the 
7iasal septum. 

The bony arch or bridge of the nose (Fig. 50) is com- 
posed of the nasal processes of the superior maxillary and 
the nasal bones. 





Fig. 50. — Bones and cartilages of the external nose. A, Side view : a, Cartilage of 
septum ; b, upper and (c) lower lateral cartilages ; d, sesamoid cartilages ; e, cellular tissue ; 
f, nasal bone ; g, nasal process of superior maxillary bone. B, View from below : a, 
Lower lateral cartilage ; b, sesamoid cartilages ; c, cellular tissue. 

The cartilaginous arch consists of the upper and lower 
lateral cartilages and the sesamoid cartilages, usualh- three 
on each side of the nose. The cartilages are bound together 
by strong connective tissue, and by the action of muscles 
upon them the opening into the nose can be dilated or 
narrowed. 



64 



ANATOMY or' TlIK NOSF. 



65 



The alee or win^^s of tlic nose contain no cartilage, Init 
consist of a mass of cellular tissue and fat. 

The nasal septum consists of bone and cartilaL^^e covered 
by mucous membrane. Its cartila<^inous portion is the 
so-called triangular <:v?;'//7r?^r, because it fits into a triani^ular 
space between the perpendicular plate of the ethmoid and 
the vomer (Fig. 51). However, the cartilage of the septum 




Fig. 51. — Osseous and cartilao^inous septum of the nose : i, Triangular cartilage of the 
septum ; 2, median plate of the lower lateral cartilage, sometimes called columnar cartilage 
and cartilage of the aperture; 3, cartilage of Jacobson ; 4, supravomerine cartilage some- 
times present ; 5, vomer; 6, perpendicular plate of ethmoid; 7, ethmovomerinc suture ; 
8, sphenoidal sinus ; 9, nasal bone ; 10, palate bone. (Arnold.) 

is quadrilateral in shape. Besides the perpendicular plate 
of the ethmoid and the vomer, the nasal crests of the 
superior maxillary, palate, and nasal bones, as well as the 
nasal spines of the superior maxillaries, enter into the 
formation of the septum, the rest of the septum fitting into 
a groove between these two sets of processes. The nasal 
septum is covered by mucous membrane, beneath which, 
near the nasal floor, is ill-developed erectile tissue, and above 
which are the specialized nerve-filaments of the sense of 
smell. 



66 DISEASES OF THE NOSE, THROAT, AND EAR 

The skill covering the external nose, especially at the 
tip, is rich in sebaceous glands, the contents of which when 
diseased form the well-known comedones. At the tip of 
the nose beneath the skin is a cushion of fat which when 
hypertrophied aids in the production of " pug nose." The 
skin extends into the nose nearly to the anterior extremities 
of the inferior turbinated bones, and at the entrance into 
the nares it is usually covered with short thick hairs, the 
vibrissae. 

The imisclcs of the external nose are the levator alae nasi, 
depressor alae nasi, levator alae nasi props, and the musculis 
apicis. These muscles by their action dilate and make 
narrow the anterior nares during respiration. 

The arteries of the external nose are the lateralis nasi, a 
branch of the facial, nasal branches of the ophthalmic and 
infra-orbital, and the septal artery from the superior coronary 
artery. 

The nerves of the external nose are branches from the 
facial, infra-orbital, infratrochlear, and the nasal branch of 
the ophthalmic. 

The nasal cavities are the commencement of the upper 
respiratory tract. They extend from the anterior nares to the 
posterior wall of the pharynx, and consist of two chambers, 
divided from each other by the septum. The floor is sepa- 
rated from the roof of the mouth by comparatively thin 
structures and hence is parallel to it. The roof is formed 
by the nasal bones and nasal spines of the frontal bone, the 
horizontal plate of the ethmoid, and the anterior wall of the 
sphenoidal cells. The lateral walls are formed by portions 
of the frontal, lacrimal, ethmoid, and sphenoid bones. 

Upon the lateral walls of the nasal chambers are the supe- 
rior, middle, and inferior turbinated bones (Fig. 5 2). The in- 
ferior turbinated is a separate bone, but the superior and 
middle turbinated are portions of the ethmoid. At birth this 
portion of the ethmoid is often divided into three or even 
four turbinated bones by grooves that disappear later in 
life. Beneath the turbinated bodies are three respective 
meati : the superior, middle, and inferior meati. The inferior 
meatus extends backward and downward, and at the junc- 
tion of its anterior third with the posterior two-thirds receives 



AjVA'/va/v of tjik nosh 67 

from beneath the inferior turbinated body the secretions of 
the eye through the nasal duct (Fi^-. 95). Its position upon 
the floor of the nose renders the inferior meatus the impor- 
tant drainage fossa of the nose, and along it the spray of an 
atomizer or the stream of a syringe should be directed if it is 
desired to wash secretions into the pharynx. Above the 
inferior turbinated body is the middle meatus, and because 
of the numerous ostea opening into it is an important fossa 
in nasal diseases. The superior turbinated body is a portion 
of the middle turbinate, separated from the rest of the middle 
turbinate by a groove, the superior meatus^ closed in front 
but opening posteriorly into the spheno-ethmoidal recess. 

The nasal cavities are divided into vestibular, respiratory, 
and olfactory regions, and the accessory cavities. 

The vestibidar region is all that portion of the nose anterior 
to the turbinated bodies. The respiratory region is the in- 
ferior nasal chambers posterior to the vestibular region, 
bounded above by the inferior edge of the middle tur- 
binated body. Through this region of the nose the respi- 
ratory air-currents arch on their way to and from the 
pharynx. The olfactory region lies above the inferior edge 
of the middle turbinated body. 

The mucous or Schneiderian membrane of the nose is a con- 
tinuation of the external tegument, and is continuous with 
that of the pharynx, the Eustachian tubes, and the accessory 
sinuses. It is sometimes called the pituitary (meaning 
phlegm-producing) membrane or the Schneiderian, after 
Schneider, an anatomist, who first proved that the nasal 
secretions were produced by it and not by the brain. In 
many portions of the nose it is thin and inseparable as a 
membrane from the periosteum or perichondrium beneath, 
but over the inferior turbinate and the adjacent portion of 
the septum, as well as the inferior edge of the middle tur- 
binate, it is thick and vascular. In these regions is the so- 
called erectile tissue, similar to that of the sexual organs, and 
consisting of cavernous blood-vessels imbedded in cellular 
tissue. When this tissue erects itself, that is, when its vessels 
fill with blood, the bulk of the nasal membrane enormously 
increases and may cause almost complete stenosis of the 
nasal chambers. 



68 DISEASES OF THE NOSE, THROAT,. AND EAR 

The vestibular mucous membrane is covered by stratified 
pavement epithelium and contains sweat and sebaceous 
glands, and anteriorly vibrissse or short hairs that serve to 
prevent the entrance into the nostrils of coarse particles of 
dust and insects. The mucous membrane of the respiratory 
region is covered- by pseudostratified ciliated epithelium 
and contains goblet-cells. Mucous, serous, and lymphatic 
glands are numerous. The mucous membrane of the 
olfactory region contains no erectile tissue and to it are dis- 
tributed the specialized nerve-endings of the olfactory nerve. 
It is covered by a single layer of cylindric epithelium and 




Fig. 52.— Nerves of nose and sphenopalatine ganglion, from inner side : i. Network of 
external branches of olfactory nerve ; 2, nasal nerve, giving its external branch to outer 
wall of nose; the septal branch is cut short; 3, sphenopalatine ganglion; 4, ramiiication 
of large palatine nerve; 5, small, and 6, external palatine nerve; 7. inferior nasal branch; 
8, superior nasal branch; g, nasopalatine nerve cut short; 10, Vidian nerve; 11, great 
superficial petrosal nerve ; 12, great deep petrosal nerve ; 13, the sympathetic nerves ascend- 
ing on internal carotid artery. 

contrasts by its yellow color with the bright pink of the 
parts below. In this thin pale membrane are the olfactory 
and sustentacular cells capable of receiving sensory impulses 
recognized as odors. 

The arteries of the nasal fossae are the anterior and pos- 
terior ethmoidal from the ophthalmic, the sphenopalatine 
branch of the internal maxillary, and the alveolar branch of 
the internal maxillary to the antrum. 

The nerves of the nasal fossae (Fig. 52) are the nasal branch 
of the ophthalmic to the septum and outer wall, anterior 
branch of the superior maxillary to the inferior turbinated 



PHYSIOLOGY OF MUCOUS MKMlikANES 69 

body,and the floor ofthc nose. The sphenopahitine <;anL;H()ii 
gives off the Vidian nerve to the septum and superior tur- 
binated body and the superior nasal branch to tiie same 
regions, the nasopahitine to the middle of the septum, and 
the anterior palatine to the middle and lower turbinates. 

The olfactory or first cranial nerves from the olfactory 
bulb enter the nose through twelve or more openings on 
eacli side of the cribriform plate. They are distributed 
to the specialized nerve-endings in the mucous membrane 
of the olfactory region of the nose. 

The lymphatics of the nose are numerous. The more 
anterior terminate in the submaxillary glands, the posterior 
communicate with the pharygneal glands. 



PHYSIOLOGY AND PATHOLOGY OF MUCOUS 
MEMBRANES AND ^'CATCHING COLD^* 

During respiration the bulk of the air passes along the 
septum above the inferior turbinated body, describing a semi- 
circle in its course, and extending upward nearly to the roof 
of the nose. Abnormal dryness of the nasal mucous mem- 
brane, or nasal obstructions of a kind to interfere with the 
free access of air to the olfactory portion of the nose, inter- 
fere greatly with the acuteness of the sense of smell. 

Aitkin, experimenting with odorous substances, concludes 
that the sense of smell is excited not, as is generally as- 
serted, by small particles of such substances resulting from 
their evaporation, but by gases. 

The nose also serves as an additional resonant cavity 
during vocalization, so that obstruction of the nasal chambers 
invariably produces a peculiar nasal intonation during speech. 
Perhaps the most important function of the nose is to warm, 
moisten, and free from dust the inspired air. In health 
exhaled air invariably has a termperature of 98.5° F., and 
it has been proved experimentally that most of the heat 
supplied to inhaled air comes from the nose, the turbinated 
bodies being well adapted not only to warm the inspired 
air, but to moisten it and free it from particles of dust which 
adhere to its moist, sticky surface. 

Dust particles removed from the skin o{ the face and 



70 DISEASES OF THE NOSE, THROAT, AND EAR 

from the vibrissae contain numerous bacteria from which cul- 
tures can be made. On the other hand, bacteria removed 
from the surface of the normal nasal mucous membrane 
evince little vitality and cultures are made from them 
with considerable difficulty. Hence it has been claimed 
that the nasal secretions possess sufficient antiseptic quali- 
ties to destroy some bacteria and inhibit the growth of others 
until they are removed from the nose by the use of the 
handkerchief The practical point from this is that irritat- 
ing antiseptic sprays before an operation are uncalled for, 
and by setting up what might be called a chemic rhinitis 
tend to promote the growth of bacteria rather than destroy 
them. This is particularly true of solutions of corrosive 
sublimate. 

INFLAMMATION OF MUCOUS MEMBRANES 

The most common forms are acute and chronic catarrhal 
inflammation, purulent, croupous, and diphtheritic inflam- 
mation. 

In acute catarrhal inflammation an increased blood-supply 
stimulates the epithelial layer of the mucous membrane to 
increased activity ; new cells are rapidly formed and cast off, 
while the glands pour out their secretion in excessive quanti- 
ties and an abundant liquor sanguinis transudes the vessels, 
the mucous membrane at the same time appearing red and 
swollen. 

Chronic catarrhal inflammation differs from acute catarrhal 
inflammation in that the subepithelial layer of the mucous 
membrane is more involved. Connective tissue is developed 
by a slow process of proliferation. Usually the mucous 
membrane is thickened and hypertrophied ; but, in some 
instances, the new tissue may be so placed as to press upon 
the glands and folhcles, giving rise to atrophy and the so- 
called atrophic or '' dry " catarrh. Also in catarrhal inflam- 
mation of the mucous membrane there sometimes occurs 
increased activity in the lymphoid cells, finally producing 
hypertrophy of the tonsils or other adenoid structures. Ac- 
tivity of morbid processes, confined largely to epithelial and 
lymphoid structures, belongs essentially to the younger 



rilYSIOLOCY OF MUCOUS M I:M i; KA XLS J I 

period of life ; while morbid activity in the connective-tissue 
structures belongs essentially to later life, rendering it much 
more difficult to bring about a cure in the catarrh of an 
adult than in that of a child. 

Croupous inflammation is of a higher grade than catarrhal ; 
for, while it commences in the same manner, with increased 
blood-supply, rapid cell-growth and proliferation, increased 
secretion, and a throwing off of immature cells, leukocytes, 
and liquor sanguinis, it differs from it in the fact that the 
exudate contains a large amount of fibrin and albumin, which 
coagulate upon the surface of the mucous membrane, form- 
ing a false membrane. This false membrane is at times so 
soft and almost granular in character as to be easily removed 
with a soft brush. At other times it is tougher and difficult 
of removal ; but, in either case, when removed, the mucous 
membrane is left intact or only deprived of some superficial 
epithelial cells. 

Diphtheritic inflammation is also characterized by the 
formation of a false membrane, but its pseudomembrane 
permeates the mucous membrane so densely that it can 
only be removed by bringing away with it the entire thick- 
ness of the mucous membrane to which it is attached, thus 
leaving the parts below completely denuded. A diphther- 
itic pseudomembrane is of a dark grayish color, resembling 
somewhat an ordinary slough of the mucous membrane, in 
contradistinction from a croupous membrane, which is of a 
bluish-pearl color, with no appearance as of sloughing of 
the parts. 

Pathology. — In inflammation of mucous membranes the 
secretions are either increased or decreased in quantity, so 
as to either flood the parts or leave them unnaturally dry. 
It should be borne in mind that the normal secretion of the 
nasal mucous membrane is over i6 ounces of clear 
watery mucus in twenty-four hours, a part of which in health 
passes unnoticed through the nasopharynx down into the 
esophagus and stomach. Only when by obstruction or 
irritation, due to any cause whatever, this easy outflow and 
abundant secretion is interfered with do we perceive a thick- 
ening and an accumulation of the secretion of the mucous 
membrane, which is designated as mucus, and is composed 



J 2 DISEASES OE THE NOSE, THROAT, AND EAR 

largely of epithelial cells in a state of fatty degeneration, 
mucous corpuscles, and the impurities filtered out from the 
inspired air. When mixed with pus or blood the secretions 
become yellow, green, or brown in color; and if retained 
upon the mucous membrane for a sufficient length of time 
the secretions become offensive as the result of putrefactive 
changes. 

" Catching cold " is the result of a transient influence upon 
the vasomotor system of nerves, producing an uneven dis- 
tribution of blood in the capillaries, especially manifesting 
itself as a congestion of the mucous membrane of the upper 
respiratory tract, followed in most instances by inflamma- 
tion, swelling, and either diminished or excessive perverted 
secretion. It is probable that the phenomena of " catching 
cold " is largely of a reflex nature, in which the peripheral 
sensory nerve fibrillae of the skin and extremities perceive 
the abstraction of heat as a shock, and being afferent in 
their conductive function, convey the impression to their 
respective ganglia, whence it is reflected by means of the 
efferent vasomotor fasciculi to the vessels, causing their di- 
latation and congestion, and, finally, inflammation of the 
structures containing them. This theory not only explains 
the ordinary phenomena of a *' cold in the head," but also 
the pain of neuralgia and rheumatism suddenly produced by 
" catching cold." Dilatation of the vasonervorum, resulting 
perhaps in the effusion of serum, produces pressure upon a 
nerve within its sheath and consequent pain in the muscle or 
skin containing it. 

The reason why the mucous membrane of the upper air- 
passages is the most frequent seat of an inflammation due to 
cold or a chilling of the surface of the body is that the sud- 
den change of temperature produces, in the first place, an 
effect upon the sensory nerve-fibers in the skin, which im- 
pression is communicated to the vasomotor centers, and con- 
sequently results secondarily in a contraction of the blood- 
vessels of that portion of the skin which has been affected. 
As there is a certain amount of blood in the vascular 
system at a given time, a sudden contraction of any portion 
of that system must, according to the law of hydrostatics, 
cause a corresponding dilatation at some other portion, 



DISEASES OE THE NOSE 73 

which is tliat portion which is least able to resist tlie pres- 
sure. Inasnuich as our variable climate, the impurities 
of the atmosphere, and our artificial way of livin^^ have a 
tendency to weaken the capillaries of the upper air-pas- 
sages from early childhood, that portion of the human 
economy is therefore the region most liable to suffer from 
this unequal distribution of blood. There results, first, 
engorgement of the parts with increased secretion and, 
finally, inflammation. 

DISEASES OF THE NOSE 

Effect of Disease of the Nasal Passages on Other Parts of 
the Body. — Nasal disease may extend to the pharynx, ear, 
or larynx by continuity of structure, or affect the other res- 
piratory organs by abeyance of the functions of warming, 
moistening, and filtering the inspired air, so that it enters the 
pharynx cold, dry, and dust-laden, thus producing inflam- 
mation of the pharynx, larynx, and even of the parts 
below them. Chronic laryngitis frequently results from 
this cause ; and while it is not easy to prove that pneu- 
monic phthisis is directly the result of atrophic rhinitis, yet 
it is difficult not to suspect some such relationship between 
the two diseases. As the result of nasal disease there 
are often induced certain reflex phenomena, viz., nasal cough, 
nasal asthma, nasal vertigo, nasal epilepsy, nasal chorea, 
hay-fever, pareses of the palate and larynx, neuralgia and 
headache, reflex skin rashes, affections of the eye, both in- 
flammatory and muscular, and diseases of the ear. 

The term " reflex " is, doubtless, often misapplied, yet it 
has a definite significance, and the reflexes which originate 
in nasal or nasopharyngeal irritation and terminate in cough, 
laiyngeal spasm, or asthma, follow much the same pathway 
as the reflex known as sneezing. The nasal branches of the 
ophthalmic division of the fifth nerve and the nasal branches 
of the anterior palatine descending from Meckel's ganglion, 
which is in connection with the superior maxillary division 
of the fifth nerve, conduct the sensory impressions to the 
medulla. It is there reflected to the respirator}^ pneumo- 
gastric, and other centers, whence the deep inspiration, the 



74 DISEASES OF THE NOSE, THROAT, AND EAR 

forced expiration, and the coincident spasm of the pharyn- 
geal and laryngeal muscles, termed a sneeze. 

Acute rhinitis is an acute catarrhal inflammation of the 
nasal mucous membrane. 

The synonyms are coryza ; cold in the head ; acute nasal 
catarrh ; in children, the snuffles. 

Etiology. — It is generally the result of exposure to cold 
and wet when the body is overheated. It may, however, be 
produced by breathing hot dry air or inhaling irritating 
vapors and dust, errors of diet, or come on apparently as the 
result of a venereal debauch. Chronic catarrh, syphilis, 
rheumatism, dyspepsia, or a debilitated state of the system 
renders an individual more liable to attack. According to 
some authorities pathogenic micro-organisms play an impor- 
tant part in the production of a *' cold in the head," and it 
has been claimed that the disease is infectious. 

Pathology. — At first the mucous membrane, though 
swollen and congested, is dry. As the disease progresses, 
there is an abundant serous discharge, which becomes more 
and more charged with broken-down epithelial cells, lymph- 
corpuscles, pus-globules, etc., until the discharge assumes 
the character of a thick, tenacious mucus or mucopus. The 
deeper lying tissues also participate in the process. The 
erectile tissue becomes gorged with blood and swollen, in 
some instances completely occluding the nares. 

Symptoms. — The onset may be simply an attack of sneez- 
ing, followed by increased and thickened discharges. In 
other cases the attack begins with chilly sensations and a 
general feeling of illness. There is a sensation of fulness 
and pain about the nose and forehead. The face may be 
flushed, the eyes suffused, and more or less fever be present. 
Sensations, almost suffocating in their character, may be 
present from occlusion of the nares, and the discharges be so 
irritating as to scald the skin of the alae and upper lip. A 
cold in the head lasts from two or three days to as many 
weeks. It generally ends in complete resolution, but fre- 
quently repeated is a common source of chronic nasal 
catarrh. In nursing children the child takes nourishment 
only with difficulty, frequently pausing to breathe through 
the mouth. 



DISEASES OF THE NOSE ^^ 

Treatment. — A cold in the head can often be aborted at 
its commencement by a hot bath and a bowl of hot lemon- 
ade at bedtime, with or without lo gr. of Dover's powder, 
followed in the morning by a saline purge and the wearing 
of extra warm clothing. The turgescence of the nasal 
mucous membranes and discharges can always be abated by 
the application of a 4 per cent, solution of cocain. This 
effect of the cocain can be kept up for several hours by 
spraying the interior of the nose with a 4 per cent, solution 
of antipyrin immediately after the application of the cocain 
solution. If repeated every day, this treatment gives great 
and immediate comfort to the patient and cuts short the 
course of the disease, while a soothing snuff (Formula 53) 
used by the patient in the intervals between the applications 
adds much to the efficiency of the treatment. In severe 
cases the patient had better remain in bed, and the presence 
of fever requires the administration of aconite in small doses 
at frequent intervals. Many pill makers manufacture what 
they term rhinitis tablets, the active ingredient of which is 
belladonna ; j-^q gr. of this drug, taken every two hours for 
four or five doses or until a sensation of dryness in the 
throat is produced and then at much longer intervals, yields 
decided relief in controlling the nasal symptoms. 

Simple chronic rhinitis is a catarrhal inflammation of the 
nasal mucous membrane, exhibiting but a slight tendency to 
spontaneous recovery. 

The syiionyms are chronic catarrh ; subacute rhinitis ; 
chronic cold ; chronic coryza ; rhinorrhea. 

Etiology. — It is generally the result of uncured rhinitis 
or frequent attacks of coryza. 

Pathology. — The mucous membrane of the nose presents 
precisely the appearance seen in acute rhinitis, only it is less 
swollen and less red in color. The discharge is either 
watery, if the upper parts of the nose, especially the mucous 
membrane of the middle tubinated bodies, are the parts 
most affected ; or it approaches mucopus in character if 
the disease is mostly locate(4 in the lower parts of the 
nose. 

The symptoms are precisely those of acute rhinitis, only 
less pronounced. There is a feeling of fulness about the 



"J 6 DISEASES OF THE NOSE, THROAT, AND EAR 

nose, a continual discharge, and the sufferer is continually 
" catching cold," when, of course, all his symptoms are in- 
creased in severity. 

Prognosis. — Untreated, chronic rhinitis may continue 
indefinitely, and finally result in hypertrophic rhinitis, the 
pharynx also gradually becoming affected. Treated in the 
following manner a cure is frequently brought about in from 
three to six weeks. 

Treatment. — Ordinarily the tone of the system is below 
par and a tonic is indicated. In such cases Formula 85 
answers a most useful purpose. If the bowels are sluggish, 
it is advisable to direct the occasional use of a saHne cathar- 
tic. Cleanliness of the mucous mem.brane is of primary 
importance, and may be secured by the patient using at 
home, twice a day, a bland alkaline antiseptic wash (For- 
mulas I to 10) with an atomizer. 

The application of an alterative or an astringent to the 
nasal mucous membrane in these cases is of the greatest 
value, and the following formula has long been popular for 
this purpose : 

R lodini, gr. v ; 

Potassii iodidi, gr. xv; 

Glycerinae, f^j. — M. 

The result of the appHcation of this formula varies accord- 
ing to the amount of the solution used. When the nose 
is extremely sensitive only a small amount of cotton should 
be wrapped about the applicator, so as to form a brush 
capable of absorbing but a small amount of the solution, 
which should be carefully applied to those portions of the 
nasal mucous membrane where the inflammation seems 
greatest ; the cotton brush should also be passed along the 
floor of the nose and the application painted upon the 
pharyngeal mucous membrane. After the application of the 
iodin solution the use of some protective upon the nasal 
mucous membrane is advisable. This indication may be 
secured by means of a spray of fluid albolene, applied until 
the mucous membrane of the nose and nasopharynx is 
thoroughly coated with it. The albolene serves the pur- 
pose also of " spreading " the application previously made, 



DISEASES OE THE NOSE 77 

vvhicli, to all intents and piir[)o.scs, becomes, after tlie 
use of the cosmolin, an (jintnient thoroiiL^lily coatinc^ the 
Schneiclerian membrane. 

Instead of plain albolcnc, what is frequently referred to 
as menthol-camphor-albolenc may be employed. The 
formula is : 

K Menthol, ^r. v ; 

Camphor, ^r. x\ ; 

Albolene, ^o'J- — '^^• 

In certain cases either of the following formulas when 
applied to the nose give quicker and better results than the 
iodin solution, especially in adults : 

li Buroglycerid, 50 per cent. 

R Acidi tannici, gr. xl ; 

Glycerina.', f3J. — M. . 

A case of simple chronic rhinitis is then perhaps best 
treated in the following manner : The patient is ordered a 
tonic, instructed to wash out his nose night and morning 
with either Dobell's solution or one of its modifications de- 
scribed above, and to present himself at the physician's 
office at least twice a week, but better every other day, for 
treatment. After first cleansing the nose with a spray from 
an atomizer filled with either alkaline solution, the physician 
should make an application of the iodin solution and follow 
it with a spray of menthol-camphor-albolene. 

Purulent rhinitis is an inflammation of the Schneiderian 
membrane in which the discharge from the beginning is 
purulent. It is usually chronic in character and more com- 
mon in children. 

Etiology. — It probably always results from specific infec- 
tion of some kind. It may occur during the course of one 
of the exanthemata, diphtheria, etc. Some cases occurring 
in young infants appear to be due to gonorrheal infection 
from the vagina during birth. 

Pathology. — The bacteria characteristic of the infection 
are found in the discharges or in the mucous membrane. 
Pseudomembrane usually occurs from the presence of 



y^ DISEASES OF THE NOSE, THROAT, AND EAR 

the Klebs-Loffler bacilli or some of the other bacteria. 
Primary nasal diphtheria without systemic involvement, or 
at least systemic symptoms sufficiently severe to confine 
the patient to bed, is not a very uncommon disease. Under 
such circumstances the most noticeable symptom is com- 
plete occlusion of the nares by the swollen mucous mem^- 
brane and pseudomembrane, a culture from which yields the 
characteristic bacillus of diphtheria. When the bacteria of 
purulent rhinitis are sufficiently virulent to cause actual 
destruction of tissue, deep ulcers occur, with final formation 
of scar-tissue. The disease in childhood is probably the 
most common cause of atrophic rhinitis in after life. Some 
cases are the result of inherited syphilis. 

Symptoms. — The disease is most common in children and 
is characterized by a fetid, thin, purulent discharge, some- 
times streaked with blood, which often excoriates the lip 
and alae of the nose. The nasal mucous membrane is red, 
swollen, and ulcerated, and may or may not be partly 
covered by a pseudomembrane. An infant is often able to 
nurse only with considerable difficulty, and hence such 
infants are frequently emaciated. An improvement in the 
infant's condition consequently results as soon as the disease 
subsides sufficiently to permit nasal breathing. 

Treatment. — The nasal mucous membrane should be 
cleansed at least twice a day with an alkaline spray. 

In infants the nose is more effectively cleansed by means 
of a syringe than by the spray from an atomizer, and the 
bulb rubber ear syringe (Fig. 48) is probably most useful 
for this purpose. Extreme gentleness should be used in 
syringing, in order to prevent fluid entering the middle ear. 
In children who have not yet learned to blow their nose, 
it is best to blow it for them by inserting the syringe tip 
into one nostril and forcibly compressing the syringe -bulb. 
By this means a current of air is forced into one nostril and 
out of the other, blowing the mucus and pus before it. 
After the nose has been cleansed of the major portion of 
the secretion, Dobell's solution may be dropped in by 
means of the syringe. A small quantity of gallic acid 
ointment, from 3 to 10 gr. to i ounce of vaselin, accord- 
ing to the age of the child, should then be placed within 



D/SKASKS OF 'J'lII': NOSE Jcj 

the nostrils with a brush. This home treatment shouhl be 
carried out twice a day. 

The physician himself should treat the child two or three 
times a week or oftener by cleansing the nasal mucous mem- 
brane as described above, using an air-douche either from 
a syringe or, in the case of larger children, the Politzer bag 
to blow mucus from the nose both before and after the use 
of the atomizer. When thoroughly cleansed the nose 
should be sprayed with albolene and dusted with powdered 
calomel or aristol by means of a powder-blower, care being 
taken that none of the powder reaches the pharynx and is 
swallowed. 

In scrofulous children hygienic measures are often as im- 
portant as local treatment. Cod-liver oil and syrup of the 
iodid of iron will be required in many instances. In primary 
nasal diphtheria with pseudomembranes, these should be 
removed with forceps and peroxid of hydrogen, and the 
underlying mucous membrane painted with a 6o-gr. solu- 
tion of nitrate of silver. The nasal mucous membrane 
should then be sprayed with menthol-camphor-albolene, 
and the parts covered with calomel or some other reliable 
antiseptic powder. 

In many cases of pseudomembranous rhinitis, where the 
Klebs-Loffler bacillus is present, there is an entire absence 
of constitutional symptoms, and it often requires some 
persuasion to induce the parents to keep the child away 
from school. However, quarantine, at least to the extent 
of avoiding contact with, other children, should be insisted 
upon. At home the nasal mucous membrane should be 
sprayed every two to four hours with 3 per cent, peroxid 
of hydrogen diluted with an equal quantity of Dobell's 
solution, and then with menthol-camphor-albolene. 

Hypertrophic rhinitis is a chronic inflammation and hyper- 
trophy of the nasal mucous membrane and submucous tissues 
with hyperemia or permanent dilatation of the blood-vessels. 
Hypertrophy of an organ is due to an increase in the size 
of the cells, wdiile hyperplasia is an increase in the number 
of cells. Both conditions imply an increase in the bulk of 
an organ. In the turbinated bodies of the nose the condi- 
tions can be differentiated from the fact that in hypertrophy 



8o DISEASES OF THE NOSE, THROAT, AND EAR 

the parts are soft to the touch and shrink greatly under 
the appHcation of cocain or adrenahn, while in hyperplasia 
the parts are firm to the touch and do not shrink greatly 
under cocain. 

The sy7i07iyms are obstructive rhinitis ; hypertrophic 
nasal catarrh. 

Etiology. — It is invariably the result of long-continued 
simple chronic rhinitis or frequent attacks of coryza. It is 
said to occur most readily in the gouty and rheumatic. 

Pathology. — While in long-continued simple chronic rhi- 
nitis there is already some thickening of the epithelial layer 
of the mucous membrane, yet the disease only becomes 
hypertrophic rhinitis when the thickening involves the other 
elements of the mucous membrane and the submucous 
structures. As the result of frequent attacks of inflamma- 
tion the blood-vessels become permanently dilated and 
their walls thickened, glandular tissue is hypertrophied, 
infiltrations occur, which finally become organized into 
connective tissue, so that the thickened turbinated tissues 
cannot collapse as when normal, and remain permanently 
distended with blood. This thickening is most notice- 
able at the anterior and posterior parts of the middle 
turbinated bodies, where it is called an anterior or pos- 
terior hypertrophy. Generally as the result of trauma- 
tism, ecchondroses and exostoses occur upon the septum 
opposite the pendulous portion of the inferior turbinated 
bodies, thus increasing the nasal obstruction. Often a 
" bank " or " ridge " of cartilage and bone will extend for a 
long distance along the septum opposite the inferior turbi- 
nated body, or along the sutures of the cartilaginous and 
bony septum. 

Symptoms. — The most prominent symptoms are those of 
nasal obstruction, want of proper drainage from the nasal 
cavities, and increased secretions. When the obstruction 
is great and constant the patient becomes a " mouth- 
breather." The inspired air, under such circumstances, not 
being properly warmed, moistened, and freed from dust in 
its passage through the mouth, causes dry lips, a coated 
tongue, follicular phar}^ngitis, and sometimes chronic laryn- 
gitis. When the nasal occlusion is complete, the face 



DISEASES OE THE NOSE 



8i 



assumes a stupid expression on account of tlie constantly 
open mouth. Should the habit of mouth-breathing^ be 
acquired in early childhood and continued for some years, 
even the shape of the bones of the face is altered and the 
habit of mouth-breathing retained long after the nasal ob- 
struction has disappeared. In most cases of hypertrophic 
rhinitis any position favoring the gravitation of blood into 
the hypertrophied parts is sufficient to cause their disten- 
tion ; hence, when the patient is in bed, first one nostril and 
then the other will become occluded, according to which 
side of the body is lain upon. This is especially true 



-H-* 




Fig. 53. — Nostril dilated by Bosworth's speculum, showing anterior hypertrophy (Seiler). 

when large posterior hypertrophies are present. Obstruc- 
tion and suppuration of the nasal duct not infrequently 
occurs as the result of inflammation of the duct, begin- 
ning at its nasal orifice. An anterior hypertrophy of 
the middle turbinated body pressing on the septal nerve, 
which is a branch of the ophthalmic, frequenth' causes 
reflex eye-symptoms, such as chronic conjuncti\-itis, slight 
paresis of accommodation, and irritable retina. The olfac- 
tory slit may become closed from hypertrophy of the 
middle turbinated body, and thus intei-fere with the sense 
of smell and also that of taste to a corresponding degree. 
Redness of the tip of the nose and acne are also apparently 
in some cases the result of interference with the blood 



82 DISEASES OF THE NOSE, THROAT, AND EAR 

supply of the skin. Hearing may be gravely compromised 
from the pressure of hypertrophies interfering with the 
blood supply of the Eustachian tubes, the damming up of 
their secretions, or the extension of the disease to their 
lining mucous membrane. Headaches are often complained 
of, and a feehng of pressure or even of pain at the root of 
the nose, as the result of occlusion of the infundibulum. 

The patient frequently complains that he has " a bad 
breath." In many cases the offensive odor is due to decay- 
ing epithelium upon the tongue as the result of mouth- 
breathing or dyspepsia. At other times the " bad breath " 
of which the patient complains is perceptible only to him- 
self, and is probably due to irritation of the olfactory region 
of the nose, contrasting strongly in this respect with 
atrophic rhinitis. If any " catarrhal odor " of the breath of 




wM^mm mmMm . 



■^^^^^M 



Fig. 54. — Jarvis' transfixing needles. 

an individual with hypertrophic rhinitis be present, it is 
always more annoying to himself than to a bystander. 

Treatment. — Each case should be treated as one of simple 
chronic rhinitis until the inflammation of the Schneiderian 
membrane has disappeared, when operations should be 
undertaken for the removal of any tissue causing obstruction. 

Removal of Anterior Hypertrophies. — If large, especially 
if the hypertrophy consists of hyperplastic tissue, that is, 
tissue that does not contract when cocain is applied, the 
operation with Jarvis' needles and snare (Figs. 54 and 55) 
will be found most satisfactory. The base of the hypertro- 
phy should be transfixed with a needle and the wire loop 
of the snare so placed that it surrounds the base of the 
hypertrophy beneath the needle. The loop being drawn 
tight, the milled nut of the instrument is turned slowly until 
the wire loop has cut through the tissues. If the operation 
is done slowly little or no hemorrhage results. Anterioi' 



DISEASES OE THE NOSE 



83 



y 



hypertrophies of the middle turbinated body may, however, 
be removed in the same manner without the use of a needle. 
Small anterior hypertrophies can be removed very satis- 
factorily by simply cutting through them with 
a sharp knife to the bone. This method is of 
advantage in children, where, as the result of 
eczema of the lip and aLne, and great inflam- 
matory swelling of the skin and mucous mem- 
brane, it is difficult to do any other operation. 
If cocain be used, the cutting causes no pain, 
and may be repeated as often as the cut heals, 
until the eczema and hypertrophy have dis- 
appeared, which often occurs within a few 
weeks. 

Anterior hypertrophies may also be de- 
stroyed by means of chemic caustics. These 
applications are, however, so unsatisfactory, in 
comparison with other measures at our dis- 
posal, that it is best not to employ them 
unless nothing better is obtainable at the time 
of the operation. 

Perhaps the best method of removing an- 
terior hypertrophies is by the galvanocautcry. 
A pledget of absorbent cotton, saturated w^ith 
a 3 per cent, solution of cocain, is introduced 
into the inferior meatus and allowed to re- 
main in contact with the hypertrophy until 
it has shrunken as much as possible and the 
parts are thoroughly anesthetized. A metal 
speculum is introduced after the removal of 
the cotton and the hypertrophy exposed. 
After the platinum wire of the cautery-knife 
is at a dull-red heat it is placed upon the 
thickest part of the hypertrophy, and by 
means of gentle to-and-fro movements is 
made to cut through to the bone, when it is carefully w^ith- 
drawn, so as not to detach the eschar which it has formed. 
The operator should be careful to cut down to the peri- 
osteum before withdrawing his cautery-knife or the results 
of the operation will be far from satisfactory ; for, although 




Fig. 55. — Jarvis' 
snare. 



84 DISEASES OF THE NOSE, THROAT, AND EAR 

a superficial burn either with the galvanocautery or chromic 
acid heals very quickly and gives a certain amount of relief 
for a short time, yet the results are not as permanent as 
when the cautery-knife is made to penetrate the periosteum. 

No after-treatment is required beyond keeping the w^ound 
as dry as possible and endeavoring to avoid detaching the 
eschar before the healing process has been completed 
beneath it. Should, however, the eschar become detached 
an antiseptic and astringent powder may be applied with 
advantage to the w^ound to form an artificial scab. The 
day following the operation there may be some inflam- 
matory reaction and the nostril occluded by swelling of the 
wounded hypertrophy, tlie patient feeling as if he had caught 
cold in that nostril ; but this quickly subsides if all catarrJial 
inflainniation lias been renwveei before the operatio7i was nndcr- 
take)i. When this has not been done, slight elevation of 
temperature and inflammation of the tonsil and perhaps 
other lymphatics on the same side as the operated nostril 
sometimes occur, and indicate the presence of a mild infec- 
tion. 

Although nearly six weeks are sometimes required for the 
complete healing of a cautery w^ound, yet little inconveni- 
ence is usually experienced by the patient during the heal- 
ing process, except that during the first week the nostril is 
sometimes more obstructed than ever as the result of sw^ell- 
ing. At the end of about ten days the slough produced 
by the burning separates from the w^ound and decided' 
advantage from the cauterization is then first experienced. 
The improved respiration becomes greater and greater until 
the wound is finally entirely healed. The anterior portion 
of the turbinate then presents a somewhat pale appearance, 
with a depression indicating the seat oi the cautery appli- 
cation. The turbinate not only is diminished in size, but 
sudden change in its volume, with consequent obstruction 
of the nostril, is also prevented. The patient states he 
" does not ' catch cold ' as readily as before the operation." 

The cautery should be used judiciously, as great and 
permanent injury may result from the work of a careless or 
brutal operator. Large tracts of mucous membrane may 
be destroyed by application of the flat side of the cautery- 



DISEASES OE THE NOSE 85 

knife or the spreadinij^ over <i moist mucous surface of a 
chemic caustic. Such wounds lieai shnvly and some 
time elapses before the scar becomes covered by an epi- 
thehum that functionates properl)-. 

The galvanocautery should be used cautious!}' upon the 
middle turbinated bone, only a very small knife being em- 
ployed for the purpose. Its application to the posterior 




Fig. 56. — Fusing chromic acid on an Allen's probe : a. Heating probe to redness ; b, 
catching up a crystal ; c, heating to round into a bead ; d, finished probe. 

portion of the nose is best avoided. Because of the thin- 
ness of the cartilaginous septum and the low vitality of its 
cartilage deep cautery \vounds generally result in a perfora- 
tion. Because of the edema that sometimes results the 
cautery should not be used on the uvula, the anterior pillars 
of the fauces, the arytenoids, or the glosso-epiglottic folds 
except with extreme caution. It is permissible to remove a 
little mass of mycosis by means of the galvanocautery from 



86 DISEASES OF THE NOSE, THROAT, AND EAR 

these regions, but a very small cautery-knife should be em- 
ployed and the burn should be very superficial. 

Chromic acid is more frequently employed than any other 
chemic caustic in the treatment of anterior hypertrophies. 
It should be used in the following manner : The end of an 
Allen's probe (Fig. 56) is heated and plunged into a bottle 
containing crystals of chromic acid, some of which will ad- 
here to the probe and be withdrawn with it from the bottle. 
A further application of heat will fuse these crystals upon 
the probe, which is now ready for use. The probe may 
also be prepared for use as a cautery by wrapping a few 
fibers of absorbent cotton about its end and rubbing into it 
moist powdered crystals of chromic acid until the cotton is 
saturated with the paste. 

The parts having been cocainized, the end of the probe 
covered with chromic acid is pressed firmly into the hyper- 
trophy and pushed backward and forward over the line to 
be cauterized, and finally withdrawn. After the lapse of a 
few moments the nasal chamber is thoroughly washed with 
the spray from an atomizer containing an alkaline solution, 
care being taken that none of the resulting chromic salt 
reaches the pharynx and is swallowed, as it is poisonous. 

Chromic acid is more uncertain in its action than the gal- 
vanocautery-knife, and the same is true of trie J dor acetic acid, 
which is used in practically the same manner, except that, 
being a liquid, it cannot be fused on to the end of a probe. 

Cautery Batteries. — Any galvanocautery battery that is 
capable of heating the platinum wire of the cautery-knife 
to a cherry-red heat will answer, but a good storage-battery 
is cheaper and cleaner and less liable to get out of order 
than most primary cautery batteries. Portable storage- 
batteries can be obtained and may be charged from the 
wires of an electric light company or from four or five cells 
of the ordinary sulphate-of-copper battery used in teleg- 
raphy. For office use, one cell of a Flemming portable 
storage-battery and four Watson sulphate-of-copper cells 
to charge it with electricity will be found an efficient 
and cleanly outfit. However, such an outfit will hardly be 
sufficient for all purposes. Each cell of a storage-battery 
supplies 2-f^ volts of tension, the quantity of electricity 



DISEASES 01' IIJE iXUSE 



87 



furnished being expressed in ampere hours. A cell fur- 
nishing fifty ampere hours will supply fifty amperes for one 
hour or one ampere for fifty hours. Other things being 
equal, the number of ampere hours depends upon the size 
of the cell ; but the voltage or pressure of the current 




7. — Galvanocaiucry handle. 



depends solely upon the number of cells, each cell supply- 
ing only 2j-\ volts, regardless of its size. It requires for 
each cell four or five sulphate-of-copper cells to charge it 
efficiently. 

Electric motors are supplied that do efficient work with a 
2-volt current, and for such motors, galvanocautery-knives, 
and snares one laree stora2"e-ccll is sufficient. 





Fig. 58.— Cauterj'-knives. 



A very satisfactory electric outfit for heating cauter>^- 
knives can be constructed from ordinary dry cells such as 
can be obtained in any electric supply store for about 30 
cents a piece. For the 



laro;er knives it is safer to have as 



88 DISEASES OF THE NOSE, THROAT, AND EAR 



many as twelve cells ; for the smaller knives, three or, at 
most, six cells will be sufficient. The cells then should be 
arranged in a box in series of three and multiples of two 
and four. (Fig. 59 shows the arrangement of cells and 
binding posts.) When the cautery-knife is connected with 
binding posts i and 2 but two series of three cells are in 
the circuit and there is little danger of melting the thin 
platinum of a small knife. When binding posts i and 3 
are used, four series of three cells will be in the circuit and 
sufficient electricity will be furnished to heat the largest 
knives. The advantage of this arrangement is that when 
the cells become exhausted others readily can be purchased 

in any electric supply store. 
This arrangement of the cells 
cannot be used for small incan- 
descent lamps for purposes of 
transillumination, as the voltage 
of such lamps is commonly 
greater than that furnished by 
three cells in series. In fact, 
for purposes of transillumi-na- 
tion, it is convenient to have six 
cells in series. 

When the rhinologist's office 
is lighted from the wires of 
an electric supply station some 
form of " converter " may be 
used to secure a current suitable 
for the galvanocautery, snare, 
miniature lamps, and electric motor. Apparatus also may 
be purchased for obtaining from the companies' wires 
both a suitable galvanic and faradic current for medicinal 
purposes. 

Removal of Posterior Hypertropliies. — A Jarvis snare 
should be threaded with No. 5 imported steel piano wire, 
as the wire should have sufficient resistance not to bend 
away from the base of the hypertrophy after it has engaged 
the growth. The loop of wire should be bent to one side 
before being introduced into the nostril, so that it may the 
more readily be passed around the hypertrophy and remain 




Fig. 59.— Diagram showing arrange- 
ment of ordinary commercial dry cells 
for cautery : b^, V^, b^, Binding posts ; c, 
carbon; z, zinc. 



DISEASES OE 77/ E NOSE 89 

in position when the loop is tightened. Ik-ini^ made as 
small as possible without distortini^ it by pullin<^ down the 
sliding tube upon the handle of the instrument, the loop is 
carefully introduced alon<^ the floor of the nose until the 
posterior wall of the pharynx is reached, when the loop is 
again enlarged by pushing upward the sliding tube, and the 
instrument at the same time is slowly withdrawn as its 
handle is carried toward the septum. By this means the 
wire is made to surround the hypertrophy and a resistance 
is finally felt as the instrument is withdrawn, caused by the 
bight of the loop coming in contact with the base of the 
hypertrophy. The wire loop is now quickly tightened 
around the hypertrophy by pushing forward the instrument 
within the sliding tube, and the milled nut is quickly screwed 
downward into place. Two or three additional turns are 
given to the milled nut to be certain that the wire is tight 
about the base of the growth and that the instrument is 
held firmly in place without danger of slipping, when the 
patient may be allowed to rest. The sudden tightening of 
the wire loop occasions the patient some pain, which, how- 
ever, soon subsides, when the loop may be still further 
tightened by turning the milled nut until the patient begins 
to again experience pain. In this way, proceeding slowly 
and carefully, the hypertrophy is finally squeezed off from 
its attachment, and is generally removed clinging to the 
end of the instrument by some fibers that have been drawn 
down into it with the wire. Should, however, the growth 
not be removed with the instrument, no attempt should be 
made to dislodge it from the nose, as it forms an efficient 
plug to prevent hemorrhage, and will probably drop into 
the fauces and be expectorated within twenty-four hours 
after the operation. From thirty minutes to two hours 
should be thus consumed in removing a posterior hyper- 
trophy in order to prevent severe hemorrhage, which, from 
its situation, might be difficult to control ; the patient should 
sit a while in the doctor's office before proceeding homew^ard, 
and should be cautioned against walking rapidly, violently 
blowing his nose, or hawking and spitting. Ordinarily 
there is very little blood lost at the time of the operation, 
but for some days afterward the patient expectorates a 



90 DISEASES OF THE NOSE, THROAT, AND EAR 

blood-tinged mucus. Owing to the compression of the wire, 
the wound made by snaring a posterior hypertrophy is but 
small and generally heals rapidly. Where there are several 
posterior hypertrophies present in the nose, a second opera- 
tion may be done a week after the first. If a posterior 
hypertrophy is very small and sessile it may more easily 
be removed if the operator waits until his patient has caught 
cold, when the swollen growth is more readily grasped 
with the wire. Cocain should not be used as a local anes- 
thetic for the removal of posterior hypertrophies because it 
shrinks the tissues to such an extent that it is difficult to 
grasp the hypertropy with the snare. A lo per cent, solu- 
tion of stovain does not contract the tissues and hence is 
the preferable anesthetic for this operation. 

Ecchondroses and Exostoses of the Septum. — A localized 
cartilaginous thickening or projection from the cartilaginous 
septum is called an ecchondrosis, while a similar bony 
growth upon the bony septum is referred to as an exostosis 
or hyperplastic osteoma. Heteroplastic osteoma is a name 
given to rather a rare form of bony nasal growth which 
springs from the cellular tissue beneath the mucous mem- 
brane, is not continuous with the cartilaginous or bony 
framework of the nose, and is therefore movable. Fre- 
quently ridges or shelves of cartilage and bone are found 
extending along the septum nearly from the anterior to the 
posterior nares. Usually such growths are opposite the 
lower turbinated body or follow the suture between the 
vomer and superior maxillary or that between the triangular 
cartilage and the vomer. 

Etiology. — They are doubtless sometimes merely pro- 
visional callus that has escaped absorption and been de- 
posited upon an old fracture of the septum. The fracture 
may have been received during early childhood as the result 
of one of the numerous " bumps upon the nose " that 
children are constantly receiving. 

Symptoins. — Frequent nasal obstruction. Atrophy of the 
turbinated body opposite them is not uncommon, nor 
neuralgia of the whole side of the face as the result of 
intranasal pressure. Sometimes the crest of such growths 
is ulcerated, and a thin, irritating, sanious discharge results, 



DISEASES OE THE NOSE 9 1 

impossible to cure except by the removal of the exostosis 
or ecchondrosis. The nostril bein^- obstructed in front, the 
breath current is interfered with in such a way that there is 
a constant rarefaction of the air at the orifice of the luista- 
chian tube at each inspiration, and as the result of " vacuum 
congestion " tinnitus and, finally, otitis media and deafness 
result. 

Operations. — Localized thickenings of the cartilaginous 
septum may be cut through and removed by means of a 
small probe-pointed tenotome. When the growth is hard 
and bony it is best removed by means of a chisel or saw. 
It should be borne in mind that only that portion of the 
growth should be removed which interferes with proper 
nasal respiration. This, of course, means in most instances 
the whole of the growth. In a roomy nostril, however, and in 
atrophic rhinitis the growth may in some instances be doing 
good by occupying a certain amount of space in a nostril 
already too large, and under such circumstances its removal 
w^ould probably cause postnasal catarrh and chronic pharyn- 
gitis. The patient is prepared for operation by placing a 
piece of absorbent cotton saturated with a 4 per cent, solu- 
tion of cocain within the nostril. The cocain should be 
allowed to remain in contact with the structures to be oper- 
ated on for at least tw^enty minutes that its anesthetic effects 
may penetrate as deeply as possible. After the removal of 
the cotton the nostril should be sprayed with a i : 1000 
solution of adrenalin to render the operation as bloodless 
as possible. The line of incision should then be painted 
with a 10 per cent, solution of cocain. 

The parts to be operated upon should be exposed by 
means of the author's dilator (Fig. 21), which will be 
found very convenient for operations within the nose, because 
when once in position it is more nearly self retaining than 
any other nasal speculum, and is not easily displaced by the 
struggles of the patient during an operation. If a chisel is 
to be used the patient's head is made to rest against a firm 
support, and the edge of the chisel is placed against the 
anterior portion of the exostosis and made to penetrate as 
deeply as possible by pushing it forward with the hand. If 
necessary the operation is continued by hammering upon 



92 DISEASES OF THE NOSE, THROAT, AND EAR 

the handle of the chisel with a lead mallet until the growth 
is felt to be severed ►from its attachment to the septum. 
Ordinarily, after the use of the chisel, a few sherds of 
mucous membrane still bind the growth to the septum. 
These are severed by passing the wire loop of a snare 
around the growth, and the exostosis withdrawn from the 
nostril by means of the snare or forceps. The advantage 
of the chisel operation is the quickness with which it can 
be performed ; but after the first cut has been made the 
nostril is deluged with blood and the operator has to com- 
plete the operation entirely by the sense of touch, being 
careful to hold his chisel, while hammering upon it, with its 
b-lade exactly parallel to the septum. 

The operation is brutal and is almost invariably followed 
by syncope, as the result, perhaps, of the concussion of the 
brain caused by the blows of the mallet. When the exos- 
tosis is large the results are frequently unsatisfactory, a large 
jagged wound generally resulting from frequent appHcations 
of the chisel. The operation, if justifiable at all, is only so 
in cases where the exostosis is attached to the septum by so 
narrow a base that it may be severed by a single thrust, as 
it were, of the chisel or gouge. 

When the saw is used, it should be entered belozv the 
growth and the sawing done in an upward direction, so as 
to obscure the field of operation as little as possible by 
blood, which, of course, flows downward from the wound. 
When the shelf of bone is large and hard the operation is 
necessarily tedious ; but at any stage of the operation the 
saw may be withdrawn and both operator and patient rest, 
a plug of absorbent cotton saturated with a 4 per cent, 
solution of cocain being again inserted within the nostril. 
Under these circumstances the cocain acts as a hemostatic, 
and the probability is that the nostril will be found free from 
blood when the cotton is withdrawn, so that the operator 
can readily see to replace the saw in the cut already made. 
However, if necessary the nose may be sprayed with a 
I : 1000 solution of adrenalin from time to time during the 
operation. It is possible in some instances to secure a prac- 
tically bloodless operation ; but it should be borne in mind 
that adrenalin contracts only the more superficial vessels, and 



DISEASES OE THE NOSE 



93 



that if a large vessel is severed, especially one deeply im- 
bedded in bone, the hemorrhage may be severe. Under such 
circumstances the operation should be completed as si)eedily 
as possible and the severed mass of bone removed. The 
nostril should then be quickly " packed " with cones of 
absorbent cotton saturated with peroxid of hydrogen, as 
described in the section on Nasal Hemorrhage. It is well 
before undertaking any operation to have several cones of 
cotton prepared so as to be able to quickly control hem- 
orrhage should it occur. 

There are many varieties of Jiasai saius for sale in the in- 
strument stores. That of Sajous (Fig. 60, a), Bucklin (Fig. 



d 




Fig. 60. — Nasal saws : a, Sajous' saw ; b, Bosworth's saw ; c, Bucklin's reversible saw. 



60, r), with teeth arranged like a metacarpal saw, sever the 
bone more rapidly than the others, and hence are to be pre- 
ferred when the mass of bone to be removed is large and 
hard. Sajous' saw is the more rapid of the two. 

Not infrequently, after the bone has been completely 
severed, it will be found difficult to cut wnth the saw the 
shreds of mucous membrane by which it is still attached to 
the septum. These shreds usually can be easily cut with 
the nasal scissors. However, in most instances the snare 
(Fig. 54) is by far the preferable instrument. The snare is 
especially useful in cases where a small exostosis has appar- 
ently been completely severed, but has disappeared from 



94 DISEASES OE THE NOSE, THR0A1\ AND EAR 

view in the blood within the nose. In some of these cases 
it is difficult to locate and grasp the mass with forceps, 
and impossible for the patient to blow it from the nostril 
because of a shred or two of uncut mucous membrane ; 
under these circumstances if the wire loop of a snare is 
passed beyond the position of the exostosis and then kept 
closely in contact with the septum as it is withdrawn from 
the nose, the loop will hardly fail to encircle any shreds that 
still connect the exostosis to the septum, and after these are 
severed by closing the loop the exostosis usually is with- 
drawn from the nose with the snare by means of fibers that 
have been drawn into the tube of the snare. 




Fig. 6i. — Nasal scissors. 

Drills. — The motive power for the drill is supplied through 
a flexible armpiece (such as is used by dentists) by a small 
electromotor suspended from a movable bracket attached 
to the wall, at one side of the patient's head. Many of the 
drills and trephines offered for sale are rendered so clumsy 
by the shield designed to protect the parts about the field 
of operation from injury that the trephine and shield cannot 
be introduced more than J inch within the nostril with- 
out hiding everything from view; while the instrument is 
too short to reach from the anterior to the posterior border 
of the septum (Fig. 62). There is, moreover, so much 
rattling of the trephine inside the shield as to interfere 



DISEASES OF THE NOSE 



95 



materially with the delicacy of the sense of touch throii<^h 
it. These faults are overcome by lengthening^ the shanks 
of trephines and burrs, and constructing^ the shield as shown 
in Fig. 63. So modified, the trephine seems to possess all 
the advantages of both chisel and saw 
for the removal of bony growths from 
the septum, and none of the disad- 
vantages of either instrument. 

The operation with the drill is per- 
formed in the following manner : A 
trephine sufficiently large to remove 
at once the major portion of the exos- 
tosis is selected, and with its shield is 
adjusted to the armpiece of the elec- 
tric motor in such a manner that the 
shield will protect all parts of the nose 
from injury except those to be cut 
away. The teeth of the trephine are 
now pressed into the anterior part of 
the growth, and as the instrument is 
pushed forward a piece of bone is cut 
from the exostosis, w^hich enters the 
cavity of the trephine, where a knife 
set at an angle cuts it into pieces suf- 
ficiently small to pass through a fenes- 
tra made for this purpose. Should a 

sufficient amount of the growth not be removed by the first 
passage of the trephine through the nasal fossa, the tre- 
phine may be reapplied as often as may be necessary to 




Fig. 62. — Electric-motor 
drills. 




Fig. 63. — Gleason's electric-motor dri 



remove the entire exostosis and leave a smooth, flat sur- 
face like that made by a saw. 

When an ecchondrosis or exostosis has attached itself 
to the inferior turbinated bone, so that a synechia or 
** bridge " extends from the septum to the opposite side of 
the nostril, it is perhaps best removed by first sawing 



g6 DISEASES OF THE NOSE, THROAT, AND EAR 

through the portion next the septum, then snaring the 
attachment to the turbinate. Unfortunately, after such an 
operation the " bridge " is very hable to recur, owing to the 
granulations from the cut surfaces of each side of the nostril 
approaching each other during the healing process until 
they finally unite. To prevent this disaster, a steel probe 
may be used to break down the adhesions, or a piece of 
tin-foil or gutta-percha may be worn inside the nose between 
the cut surfaces until the healing process is complete. 
Ordinarily nasal operations, either with saw or chisel, 
require no after-treatment beside the free use of an alkaline 
wash by the patient, in order to keep the wound clean. 
There is but little inflammatory reaction and the w^ounds 
heal prompt^. 

Packing tlic nose with iodofom gauze or any other sub- 
stance after a nasal operation should be avoided if possible. 
It is only permissible to check hemorrhage or when the 
patient has to travel a considerable distance after leaving 
the surgeon's office before reaching home. Under such 
circumstances a narrow strip of iodoform gauze, previously 
saturated wath fluid albolene, should be placed in the nose 
in such a manner as to make gentle pressure upon the 
wound. Such a packing can generally be removed in from 
twelve to twenty-four hours, if care is taken to remove it 
gradually, so as not to remove the pressure from the 
wound too suddenly. 

When no dressing is used, which is by far the preferable 
method, blood-stained mucus is blov/n from the nose for 
some days after the operation. 

Tin'biuectoDiy, or removal of the whole or, at least, the 
greater portion of the inferior turbinated body, has been 
performed to secure increased breathing space, for the 
removal of malignant growths, and for other reasons. 

Turbinotomy, or the removal of a portion of the inferior 
turbinate, has been already described. The removal of a 
portion of the middle turbinate will be considered in the 
section on Ethmoiditis. Practically, turbinectomy of the 
middle turbinate is never performed. 

When sufficient nasal respiratim can be secured by 
operations on the septum, such as the removal of an 



DISKASKS OF 'J'lIE NOSE 97 

exostosis or bringing a septal deviation into the median line, 
it is better not to remove any large portion of the infeiior 
turbinated body because of the great destruction of mucous 
membrane and erectile tissue. 

Moreover, a turbinectomy done to relieve the stenosis 
caused by a deviated septum would accomplish nothing 
toward nnproving the condition of the wider nostril. As a 
matter of fact, when middle-ear catarrh results from deviation 
of the nasal septum, it frequently begins in the ear of the 
same side as the wider naris. 

The operation is done in the following manner : The 
nasal mucous membrane is cleansed with spray from an 
atomizer containuig Dobell's solution or some other suitable 
alkaline fluid. The nasal mucous membrane is then sprayed 
with a I ; 1000 solution of adrenalin in order to prevent 
hemorrhage. The upper and lower portion of the attach- 
ment of the inferior turbinate is now cocainized with a 4 per 
cent, solution of cocain. All adhesions between the 
turbinate and the septum are broken down and the saw 
inserted just beneath the articulation of the turbinate with 
the maxillary bone. The sawing is done diagonally up- 
ward and inward until the articulation is severed. Should 
the saw fail to sever some shred of connective tissue and 
mucosa that still unite the turbinate with the superior 
maxilla, these are cut with a pair of scissors and the 
turbinate grasped with a pair of forceps and removed from 
the nose. 

Should hemorrhage render such a procedure necessary, 
the nostril is packed with iodofom gauze saturated with 
peroxid of hydrogen and the patient placed in bed. This 
packing is removed permanently after tw^enty-four hours 
unless renewed hemorrhage necessitates replacing the pack- 
ing. During the period required for the healing of the 
wound the nose is cleansed with Dobell's solution and the 
wound covered with a powder consisting of equal parts of 
aristol and stearate of zinc. 

Atrophic rhinitis is an atrophic condition of the nasal 
mucous membrane, usually also of the submucous tissues ; 
and occasionally of the turbinated bones and septum. The 
disease is characterized by a lessening in the size and thick- 



gS DISEASES OF THE NOSE, THROAT, AND EAR 

ness of the intranasal anatomy, a change in the color of the 
mucous membrane, and partial loss of function as the 
result of a decrease in the number of component cells, 
hence the formation of crusts of inspissated and putrid 
mucus which emit a fetid and offensive odor. 

The synonyms are dry catarrh ; atrophic nasal catarrh ; 
in children, scrofulous rhinitis; and where there is a stench, 
ozena. 

Etiology. — Atrophic rhinitis is said to result from long- 
continued hypertrophic rhinitis. An abnormal dryness of 
the atmosphere, like that produced by hot-air heaters, 
abnormal patulency of the nares, or anything else that 
causes a rapid evaporation of the nasal secretions, tends 
to produce atrophic rhinitis. Bosworth stated that in 
many instances the disease begins in childhood as a puru- 
lent rhinitis. Any infection with bacteria virulent enough 
to cause destruction of the nasal mucous membrane over 
comparatively large areas will produce atrophic rhinitis. 
The writer has seen it occur in the adult as the result of 
syphilis, and probably the larger majority of cases are the 
result of the destruction caused by pseudomembranous 
rhinitis and nasal diphtheria. Suppuration of the accessory 
sinuses also may be either a cause or the result of atrophic 
rhinitis, and there is said to be present in most cases the 
bacillus fcetidus ozaenae, which was formerly thought to be 
the cause of the disease. Bacteria of various kinds swarm 
in the semiputrid, half-dried secretions, and the stench is 
either directly the result of such masses, or may originate 
from the contents of suppurating accessory sinuses, or from 
masses retained in the crypts and folds of the third tonsil. 
The bony structures atrophy as the result of a rarefying 
osteitis affecting mostly the turbinates. 

Pathology. — When the disease is the result of long- 
continued hypertrophic rhinitis, the pressure of adventitious 
cellular tissue causes absorption of the glandular elements. 
The surface of the mucous membrane being thus nearly 
deprived of its secretions, is exposed to dust and irritants 
of every kind that accumulate upon it, and with long- 
retained and rotting semi-inspissated secretions, form bad- 
smelling scabs and crusts. Owing to pressure from these 



DISEASES OE THE NOSE 99 

scabs, shallow ulcers occur beneath them, while the atrophy 
progresses until, in sonic cases, the turbinated bones have 
nearly disappeared and the septum has become, at certain 
parts, almost as thin as a sheet of writing paper. It is not 
uncommon for individuals to present themselves to the 
surgeon with hypertrophic catarrh existing in one nasal 
cavity, whilst atrophic rhinitis is present in the other. In 
such cases there is usully deviation of the septum toward 
the hypertrophic side. Cases are not infrequently seen 
with an inferior turbinated body and the adjacent mucous 
membrane atrophied, whilst the middle turbinated body 
immediately above is greatly hypertrophied. 

Concomitant disease of the ethmoid cells or of some one 
or more of the other accessory sinuses of the nose is not 
uncommon in atrophic rhinitis, and it has been claimed that 
atrophic rhinitis may result from suppuration of one of the 
accessory sinuses. When superficial necrosis results from 
bacterial infection the progress of the disease, after the for- 
mation of ulcers, is similar to that described above. Retained 
secretions putrefy and produce a characteristic odor, horribly 
offensive, the disease being then termed ozena. Similar 
stenches occur in syphilitics, the stench resulting usually 
not from fetid semi-inspissated mucus, but from sequestra 
of dead bone within the nose. 

Somewhat numerous varieties of bacteria are found in 
the secretions of atrophic rhinitis, the saprophytes, or those 
causing putrefaction, naturally being the most numerous. 
Attention has not infrequently been called to the large pro- 
portion of cases of pulmonary tuberculosis among patients 
with atrophic rhinitis ; for instance, Theisen reports 14 
cases of pulmonary tuberculosis among 40 cases of ozena 
examined. It has been suggested that the large proportion 
of consumptives is due to the fact that atrophic rhinitis de- 
prives the nose of its power to arrest and destroy the bac- 
teria of inspired air. 

Symptoms. — A sensation of dryness and irritation within 
the nose and pharyngeal vault, with almost constant efforts 
to remove the accumulated secretions by hawking, spitting, 
and blowing the nose. The breath is usually fetid, but 
the patient, because of his defective sense of smell, is un- 



lOO DISEASES OF THE NOSE, THROAT. AXD EAR 

aware that his breath is horribly offensive. Upon inspec- 
tion, the mucous membrane is found diy and glazed, with 
scabs and pus adhering to certain portions of it. Sometimes 
the nostrils are so patulous that the posterior phar}mgeal 
wall can be plainly seen through them, and it also is 
usually in an atrophic condition. Reflex skin rashes and 
laryngitis are ver^' common as the result of this affection. 

Treatment. — The indications are to secure and maintain 
absolute cleanliness of the nasal mucous membrane, and 
replace, if possible, the atrophied parts. Cleanliness may 




Fig. 64. — Anterior nasal douche and method of using it (Casselberr\'). 



be secured by the patient's use of an alkaHne wash. For 
this purpose Dobell's solution or, in fact, any of the ten 
formulas mentioned on page 494 answers sufficiently well. 
When there is considerable trouble in loosening and re- 
moving dried secretions, peroxid of hydrogen diluted with 
I or more parts of Dobell's solution may be employed 
with an atomizer. Not infrequently the spray from an 
atomizer, in the hands of a patient, fails to dislodge accumu- 
lations, and under such circumstances Thudicum's douche 
(Fig. 64) is a permissible instrument, as in atrophic cases 



DISEASES OE THE NOSE 



lOI 



there is less danger of fluid entering the T^ustachian tubes 
than when the nostrils are blocked by hypertrophies. 
However, when one side of the nose is wider than the 
other the douche should alwa}'s be used from the narrower 
toward the wider side. A safer instrument for patients' 
use is the modification of the postnasal syringe shown in 
Fig. 65. This the patient is easily taught to introduce 
behind his palate. It is not only safer but more efficacious 
for removing secretions than the douche. It is nearly as 
safe as an atomizer. However, the fact 
should always be remembered that 
somewhat numerous cases of middle- 
ear suppurations have resulted from 
fluid penetrating the middle ear when 
sniffed from the hollow of the hand, 
a cup, an Alhngham douche, or the 
use of Thudicum's douche ; and hence 
these methods of cleansing the nose 
should not be emplo}'ed by the patient 
unless it is absolutely impossible to 
keep the nose clean by the use of an 
atomizer. Moreover, when the patient 
is wearing Gottstein's cotton cylinders 
within the nose there is usually no 
trouble in removing with an atomizer 
the secretions, as crusts usually cease 
to form. 

For the rhinologist's use in cleans- pio. 65.-Postnasai douche, 
mg the nose of an atrophic case the Modified for pat.ems' use, 
dental bulb syringe (Fig. 38, r, with 

postnasal tip i) answers the most useful purpose. The 
distal extremity of the tip should be nitroduced behind the 
palate of the patient, who bends his head forward over a 
bowl. The rhinologist should then compress the bulb with 
considerable force, so that the fluid (which should be warm) 
flows in a rapid stream from the nasopharynx through the 
nostrils into the bowl. 

Excellent results follow applications of lignol diluted 
with an equal quantity of sweet oil (Formula 36). T. Bobone 
uses for the same purpose : 




I02 DISEASES OF THE NOSE, THROAT, AND EAR 

R Petroleum, gm. 40.00 ; 

Olei eucalypti odoris citri, gm. 0.50; 

Strychnine nitratis, gm. 0.02. — M. 

Good results follow massage of the atrophied mucous 
membrane with a cotton-tipped probe. 

Powders, possibly because of the mechanical irritation 
they cause, do good in some cases, and for many years the 
writer was in the habit of employing a powder composed 
of a small proportion of nitrate of silver diluted with starch 
(in the earlier days of rhinology) or stearate of zinc. More 
recently the main dependence, as far as applications are 
concerned, has been upon lignol (Formula 36). 

The best results are obtained in the treatment of atrophic 
rhinitis by the use of cylinders of absorbent cotton, as first 
advocated by Gottstein (Fig. 66), so placed inside the nose 



Fig. 66. — Allen's nasal applicator with Gottstein's cotton plug ready to be deposited 
inside the nose. After the cotton is within the nose the probe is detached from the cotton 
and withdrawn by turning it in a direction opposite to that by which the cotton was 
wrapped. 

as to perform the functions to a certain extent of the atro- 
phied turbinated bodies. If pharyngitis sicca is present, the 
cotton cylinders should be of sufficient length to extend 
the entire length of the nasal floor and project somewhat 
from the posterior nares. The presence of the cotton 
cylinders excites the atrophied mucous membrane to 
renewed action, so that the dried secretions are washed 
away in the increased discharge and the fetor of the breath 
corrected. The cotton cylinders soon become soaked with 
mucus, so that the air passing around them is warmed, 
moistened, and freed from dust, and enters the pharynx 
and larynx as if it had passed through a healthy nose. This 
is the result partly of mechanical irritation and partly of 
the rarefaction of the inspired air — a factor that should 
not be overlooked in the treatment of atrophic rhinitis, as 
irreparable damage results from the removal of an exostosis, 
especially if located well forward. 



DISKASKS OF J HE NOSE I03 

A cotton cylinder is easily made by loosely wrapping ab- 
sorbent cotton about an applicator (Fig. 66) until it has as- 
sumed the desired bulk and shape. The cotton is then 
placed inside the nose and the applicator removed by turning 
it in a direction opposite to that by which the cotton was 
wrapped about it. The patient should be taught how to 
make and place these cotton cylinders inside his nose, and 
should insert fresh ones as soon as the old are removed by 
the use of the handkerchief If worn constantly they cause 
an immediate change for the better in all the symptoms of 
atrophic rhinitis and stimulate the renewed growth of the 
atrophied tissues. 

The average case of atrophic rhinitis without disease of 
an accessory sinus is best treated in the following manner: 
At the first office visit the nasal and nasopharyngeal mu- 
cous membrane is thoroughly cleansed and all adherent 
masses removed. Lignol (diluted with an equal amount 
of olive oil) is then thoroughly applied to the entire sur- 
face and carefully worked into all angles and spaces, such 
as those about the remains of the turbinated bodies. At 
the third or fourth office visit at intervals of three or four 
days the mucous membrane will have assumed a more 
normal appearance, and the patient should be taught to 
make and insert Gottstein's cotton cylinders. As soon as 
he has learned to do this properly and cleanse his nose 
efficiently the office visits should be made at less frequent 
intervals. 

He is ordered for home use a wash and instructed how 
to use it, either with an atomizer or douche. After cleans- 
ing the nose he should apply twice a day, by means of a 
brush, either lignol or Bobone's formula previously referred 
to. If pharyngitis sicca and reflex laryngeal symptoms 
are very annoying, small doses of iodid of potash (gr. ii to 
X, t. i. d.) may also be ordered with advantage to increase 
the secretions and diminish reflex action. 

Prognosis. — Atrophic rhinitis is one of the most unsatis- 
factory and tedious of nasal diseases to treat. Fetor of the 
breath and the other more annoying of the patient's 
symptoms are easily and quickly corrected in the majority 
of cases by the wearing of Gottstein's cotton cyHnders, and 



I04 DISEASES OF THE NOSE, THROAT, AND EAR 

something very like a cure of the disease, after some years, 
will be finally brought about. 

The writer occasionally sees cases that he treated ten or 
more years ago. Some of these cases are cured to 
the extent that there is no fetor of the breath or retained 
secretions requiring removal, except during periods when 
the patient has caught cold. Others of these cases still 
wear the cotton cylinders, although not constantly, and by 
this method and by the use of nasal washes manage to 
maintain a fair degree of comfort. In some cases there has 
been a partial restoration of the sense of smell. 

It is reported that actual cures have resulted from the 
employment of the Finsen ray. 

Attempts have been made with more or less success to 
restore the original bulk of the turbinals by the injection of 
paraffin wax (Formula 96) underneath the nasal mucous 
membrane. 

Syphilitic rhinitis is a diseased condition of the interior of 
the nose dependent upon the presence of syphilitic virus. 

The synonyms are syphilitic catarrh or ozena ; specific 
rhinitis ; and, according to the stage of the disease, nasal 
chancre; syphilitic coryza; nasal gumma; tertiary nasal 
syphilis. 

PatJiology. — It is exceedingly rare to find the primary 
lesion of syphiHs or chancre existing inside the nose, from 
the fact that the syphilitic virus is rarely introduced inside 
the nasal chambers, and that, should such an event occur, 
the secretions of the parts tend to wash away the morbid 
matter before inoculation takes place. Secondary lesions 
of the nasal mucous membrane are analogous to, and often 
coincide with, those appearing upon the skin. They vary 
from a mere erythema of the nasal mucous membrane with 
increased secretion to intense hyperemia and swelling, with 
the presence of mucous patches or shallow ulcers, secreting 
a sanious and offensive mucopus. During the tertiary 
period nasal gummata are by no means rare. They appear 
as irregular nodulated swellings distending the mucous 
membrane of any part of the interior of the nose. A nasal 
gumma may be absorbed, leaving in some instances a 
characteristic cicatricial contraction, or it may break down 



DISEASES OE 'J'JIE NOSE IO5 

and produce an ulcer, before wliicli the cartila^^es and even 
the bony structures of the nose may melt away like wax as 
the ulceration rapidly extends, thus producing in a 
marvelously short time the most hideous deformity. ICx- 
uberant granulations may spring from the ulcerating gumma 
and completely fill the nasal chamber or even project from the 
nares, simulating a malignant growth. When the ethmoid 
has thus been necrosed and exfoliated, there may remain, 
after the healing process is complete, but a thin fibrous 
membrane between the interior of the nose and brain. The 
lateral wall of the nose may be destroyed entirely, so that 
the antrum of Highmore and the affected side of the nose 
become one large cavity. In other instances the septum, 
nasal processes of the superior maxillary, and the nasal 
bones may be partly destroyed in such a manner that the 
nose becomes flattened upon the face, producing a most 
serious deformity. In aggravated cases the soft parts may 
also be involved in the process, until finally the anterior 
nares are represented merely by an irregular hole in the 
face. During the ulcerative process of a gumma the breath 
is generally very offensive. Hereditary syphilis pursues 
the same course as the tertiary form of the acquired disease. 
Treatment. — Constitutional treatment is of primary im- 
portance. The primary and secondary lesions are probably 
best treated by the internal administration of a pill contain- 
ing \ gr. of the protoiodid of mercury (Formula 74). The 
patient may take from one to three of these pills three or 
four times a day and, if necessary, a sufficient quantity of 
opium should be administered to prevent their producing 
diarrhea. The pills are less likely to produce digestive 
derangements if taken after meals and at bedtime. Any 
ulceration upon the nasal mucous membrane should be 
touched every other day \vith the acid nitrate of mercury 
(i part to 4 parts of water) until they are healed; and the 
inflammation treated in the meanwhile as a case of simple 
chronic rhinitis. However, although the applications of acid 
nitrate of mercury are effectual in bringing about a rapid 
healing of the ulceration, they are somewhat painful ; and 
if the patient complains bitterly of the pain, a solution of 
nitrate of silver (60 gr. to i ounce) should be substituted 



Io6 DISEASES OF THE NOSE, THROAT, AND EAR 

or the ulcerations merely may be dusted with powdered 
calomel. 

In tertiary syphilitic rhinitis the mixed treatment answers 
a very useful purpose, for, while the iodid of potassium is 
not a specific in syphilis in the sense that mercury is, yet it 
gives a much quicker result in controlling tertiary manifesta- 
tions. One, two, or three teaspoonfuls of Formula 73 may 
be given three or four times a day, according to the emer- 
gencies of the case and the patient's susceptibility to mercury. 
Mercury may also at the same time be administered by 
inunction or fumigation, or, in cases where the most speedy 
effect possible upon the syphilitic lesion is desired, it may 
be administered hypodermically. From 8 to 20 minims of 
Formula 76 should be injected into the cellular tissue of 
the back every day or at less frequent intervals. If thrown 
into the cellular tissue of the back, a solution of corrosive 
subHmate not stronger than that of Formula j6 will not 
produce an abscess, but causes some pain. The first in- 
jection should be given deep into the cellular tissue beneath 
the skin under one shoulder-blade ; the second injection, 
beneath the skin of the other shoulder-blade ; the third, 
4 inches below the first ; the fourth, 4 inches below 
the second, and so on down the back. But a few 
hypodermic injections are ordinarily required to limit the 
spreading of a gummatous ulcer, which speedily assumes a 
more healthy appearance. In cases where gummata are so 
situated as to cause obstruction to nasal respiration, pain, 
and intense headaches from pressure, the action of medicines 
upon the growth are too slow and operative procedures 
must be resorted to. A gumma may be removed from a 
turbinated bone with the snare or scraped from the septum 
with a large nasal curet. Such operations, however, should 
not be performed upon patients of debilitated constitutions, 
or those who are not, or cannot quickly be brought under 
the influence of mercury, as otherwise the wound made by 
the operation will not heal and may result in extensive 
ulceration. When a nasal gumma has broken down and is 
ulcerating the parts should be kept scrupulously clean by 
the use of an antiseptic solution (Formulas i to 10), and the 
wound stimulated to heal by the daily application of acid 



DISEASES OE THE NOSE I07 

nitrate of mercury diluted with 4 parts of water. Wounds 
resulting from operations upon gummata should be treated 
in the same way until the healing process is complete. 

Tubercular rhinitis is an inflammation of the interior of 
the nose characterized by the presence of the tubercle 
bacilli. 

Etiology. — The disease is usually the result of the inocu- 
lation of the nasal mucous membrane by morbid material 
from another portion of the body of a tuberculous indi- 
vidual. 

Pathology. — The most common lesion observed is a small 
ulceration, usually on the septum or floor of the nose. 
Occasionally hyperplastic nodules and papillomata, pale in 
color and either pedunculated or sessile, are observed. 

Syniptouis. — Crusts form upon the ulcerations and are 
blown from the nose. The ulceration may progress to per- 
foration of the septum. The hyperplastic growths some- 
times attain sufficient size to cause nasal obstruction. 

DiagJiosis. — The disease in its ulcerative form somewhat 
resembles syphilis. However, as it rarely occurs except in 
individuals with advanced pulmonary tuberculosis, the diag- 
nosis usually is easy. The surrounding mucous membrane 
usually is much paler than in syphilis ; indeed, the whole 
mucous membrane of the nose is usually anemic. How- 
ever, in doubtful cases, iodid of potassium exhibited for a 
few days in lO-gr. doses every three or four hours will 
usually decide as to w^iether syphilis is the cause of the 
ulceration. Papillomatous outgrow^ths examined micro- 
scopically show the presence of tubercle bacilli. 

Treatment. — The local treatment consists of cleanliness 
of the nasal cavities brought about by the patient's use of 
an atomizer containing an alkaline wash, followed by spray- 
ing the nose with menthol-camphor-albolene. The phys- 
ician may cleanse the ulcerations and touch them with solid 
nitrate of silver fused on the end of a probe (Fig. 55). Large 
papilloma may be snared, but it is advisable to do no un- 
necessary surgery in a tuberculous nose. As the disease 
rarely if ever occurs except in advanced pulmonary tuber- 
culosis, the general treatment is more important than the 
local. 



I08 DISEASES OF THE NOSE, THROAT, AND EAR 

Lupus. — The name lupus is applied somewhat loosely to 
various skin diseases : Lupus erythematosa, lupus congestiva, 
lupus superficialis, lupus sebaceus. Lupus erythematosa 
first appears as grouped red spots that ultimately coalesce 
into slightly raised patches. The initial lesion is always 
erythematous and, unlike lupus vulgaris, there is no tend- 
ency toward ulceration. 

Lupus vulgaris sometimes originates at the tip of the nose, 
either upon the mucous or, more often, on the skin surface. 

Etiology. — The cause of the disease is tubercle bacilli. 

Pathology. — The lesion manifests itself as reddish-brown 
nodules. These atrophy, leaving scars, or ulcerate, involving 
sometimes large areas of skin, mucous membrane, and car- 
tilage. A large portion of the tip of the nose and septum 
may be destroyed. The ulcer is often covered by a brownish 
scab ; when this is removed the ulcer appears filled with a 
granular '* apple-jelly "-Hke mass, which can be readily 
scraped away with a curet. Deep cicatrices and deformities 
result from the healing of the ulcer. It may cicatrize at 
one extremity while the progress of the ulceration is active 
at the other. The disease is uncommon in America. 

Diagnosis. — Lupus so much resembles syphilis that the 
diagnosis usually has to be established by the " therapeutic 
test," which consists in the exhibition of iodid of potassium. 
From epithelioma it is differentiated by the microscopic 
findings. 

Treatment consists in the daily application of the ;r-ray. 

Rhinoscleroma is a disease of the mucous membrane of 
the nose extremely rare in North America, but occurring in 
Brazil, Russia, Italy, and other countries. 

Etiology. — According to some authorities the disease is 
the result of the presence of a characteristic bacillus. 

Pathology. — The disease produces nodular hypertrophies 
on the nose and sometimes within the nose, pharynx, and 
larynx. Ulcers appear upon the mucous surfaces resembling 
the lesions of tertiary syphilis. The contraction of dense 
cicatrices sometimes results in deformities. 

Symptoms. — There is little or no pain at any stage of the 
disease. The growth inside the nose may interfere with 
nasal respiration, and when the mouth and pharynx are in- 



DISEASES OF 77/ E AOSE I O9 

volved it may be impossible for tlie patient to swallow solids. 
Involvement of the larynx may be sufficient to interfere 
with respiration as the result of cicatricial contraction. 

Treatment. — As the disease has a tendency to recur, 
operative interference is inadvisable, except tracheotomy 
when necessary to prevent death from stenosis of the larynx. 
Lang recommends salicylic acid locally and in io-i,n-. doses 
internally. 

Foreign Bodies in the Nose. — Children and insane persons 
occasionally insert into their noses buttons, cherry-stones, 
beads, beans, twigs, hair-pins, etc. Necrosed bones, when 
detached, act as foreign bodies and produce their charac- 
teristic symptoms. Rhinoliths, ascarides, and maggots are 
also found in the nose, and may be considered as foreign 
bodies. 

Syjuptonis. — Obstructed nasal respiration proportionate to 
the size of the foreign body. If the foreign body is large or 
causes pressure, headache and pain of a neuralgic character 
are complained of. At first the presence of a small foreign 
body in the nose of a child attracts but little attention un- 
less the child tells its parent there is something in its nose. 
After a time a discharge of glairy mucus occurs, which 
excoriates the skin of the lips and alae, but the discharge 
soon becomes purulent and may be streaked with blood 
and be fetid. A one-sided discharge from a child's nose is 
almost pathognomonic of a foreign body, and under such 
circumstances the most careful and painstaking search 
should be undertaken to discover the offending particle. 

Rhinoliths generally contain as a nucleus a foreign body 
around which the nasal secretions accumulate and deposit 
a coating of earthy salts, gradually increasing in thickness. 
The presence of a rhinolith causes practically the same 
symptoms as that of a foreign body of similar size and 
shape. 

Treatment. — The foreign body or bodies should be 
removed as soon as possible. This may be accomplished 
by means of a pair of forceps or a blunt ear curet. 

RJiinolitJis may sometimes be removed whole or may 
have to be broken up by means of a powerful pair of for- 
ceps in order to remove them from the nose. 



no DISEASES OF THE NOSE, THROAT, AND EAR 

Neuroses of the Nose. — Motor Neurosis. — Twitching of the 
nose and eyeHd is generally due to peripheral irritation of 
some branch of the facial nerve. It occasionally occurs as 
the result of the apphcation of the galvanocautery to an 
anterior hypertrophy. 

Paralysis of the dilatores nasi produces a collapse of the 
lateral walls of the anterior portion of the nose that decided- 
ly interferes with nasal respiration. Unilateral paralysis of 
the dilator nasi occuring in childhood, according to some 
of the older writers, is one of the causes of deviation of the 
nasal septum. The partial stenosis in long thin noses, due 
to the valvular action of the anterior portion of the sides of 
the nose by which inspiration is impeded, can be entirely 
alleviated by cutting a strip of requisite length from a visit- 
ing card, bending it, and placing it with its ends up inside 
the vestibule of the nose in such a manner that it acts as a 
spring holding the anterior nares open. However, in such 
cases the valve-like action of the anterior portion of the 
sides of the nose disappears permanently in many instances 
by increasing the breathing space by the removal of a small 
ecchondrosis from the septum or cauterization. 

Sensory Neuroses. — Anosmia, or complete loss of the 
sense of smell, may be congenital or acquired. If acquired, 
the condition may be due to syphilis, hysteria, or result 
from lesions of the olfactory bulbs produced by meningitis, 
tabes, or the pressure of a brain tumor. Disturbances of 
the sense of smell amounting to almost complete loss occur 
from any cause that prevents odorous particles reaching the 
portions of the nose where the peripheral nerve-endings of 
the olfactory nerves are distributed. 

An ordinary cold, hypertrophic rhinitis, or polypi fre- 
quently cause mechanically greater or less loss of the 
sense of smell, which returns after the mechanical ob- 
struction is removed. In atrophic rhinitis affecting the 
vaults of the nasal chambers there is generally great im- 
pairment of the-sense of smell, which in some cases is partly 
restored when crusts and accumulations no longer form. 
In purulent inflammation of the ethmoid cells, especially 
in those cases where the middle turbinates are sufficiently 
swollen to press on the septum, great impairment of the 



DISEASES OE 77/ E NOSE I I I 

sense of smell is usually present. In sueh cases the pro<^- 
nosis is not entirely unfavorable. 

HypcrosDiia is an increased sensibility of the olfactory 
apparatus. The ability to detect odors, generally stenches, 
is intensified. The condition is sometimes observed in 
nervous women. 

Parosmia is a perversion of the sense of smell associated 
with local or systemic disturbances, insanity, etc. The 
sensation of a bad odor is sometimes a part of the aura of 
epilepsy. 

Hyperesthesia and anesthesia of the nasal mucous mem- 
brane are occasionally encountered. 

Paresthesia^ or the sensation of imaginary stenosis or 
foreign bodies in the nose, occurs in a certain proportion of 
neurotics. It is not an unusual thing for such patients to 
complain of stenosis when the condition present is atrophic 
rhinitis with widely patulous nasal chambers. 

Reflex nasal neuroses are asthma, sneezing, cough, and 
certain skin rashes upon the nose and sides of the face. 
Cases of epilepsy have been reported as greatly improved, 
possibly cured, by the removal of nasal growths. 

The most common condition found in asthma of nasal 
origin is nasal polypi ; but semi-occasionally asthma is 
greatly alleviated by the removal of a septal exostosis or 
even by bringing about an improved condition of the nasal 
mucosa when no gross lesions are present. 

Hay-fever, or coryza vasomotoria periodica, is a chronic 
nasal affection depending upon a disturbance of the entire 
nervous system, and particularly of the various nerves 
supplying the nasal mucous membranes, and characterized 
by periodic exacerbations caused by inhaling dust or other 
irritants. 

The synonyms — hay-asthma, autumnal catarrh, rose cold, 
horse cold, cow cold, peach cold, snow cold, miller's asth- 
ma — are names given to the affection and supposed to indi- 
cate the irritant which is the direct cause of an attack of 
the disease. 

Etiology. — There are three factors in the causation of an 
attack of hay -fever, viz. : First, a pathologic condition of the 
nasal chambers ; this may comprise anterior or posterior 



112 DISEASES OE THE NOSE, THROAT, AND EAR 

hypertrophies, exostoses, ethmoiditis ; but more especially 
the presence of hypersensitive areas, readily distinguished 
by their heightened color and slight elevation above the 
surrounding mucous membrane. Irritation of one of these 
spots with the end of a probe, even during the winter time, 
will bring on an attack of hay-fever lasting from an hour to 
several days ; second, a diseased or, at least, an irritable 
condition of certain nerve-centers, giving rise to a train of 
near and remote symptoms by reflex action ; third, the 
presence of an external irritant. The absence of any one of 
these factors is sufficient to prevent an attack. 

Symptoms of an attack of vasomotor coryza are those of 
coryza — a sense of dryness and itching in the nose, violent 
sneezing, occlusion of the nares, and profuse watery dis- 
charge. These symptoms are usually followed by 
conjunctivitis, lacrimation, photophobia, headache — often 
of a neuralgic character — a hacking cough, asthma, and a 
general feeling of malaise. 

Treatment, — The most effective treatment of periodical 
hyperesthetic rhinitis is a sea-voyage, lasting through the 
entire hay-fever season or residence in a region free from 
the presence of irritating pollens and dust, like that of the 
White Mountains of New Hampshire. 

For professional and business men, however, such a treat- 
ment involves hardships and loss of business opportunities 
that render it acceptable only as a last resort. Therefore 
any treatment that will enable the sufferer to remain at home 
in comparative comfort and attend to business is eagerly 
sought by the majority of workers suffering from hay-fever. 

The attention of the profession, chiefly through the 
writings of Seth Scott Bishop of Chicago, has been directed 
to the fact that the neurotic condition of the patient and the 
hypersensitiveness of the nasal passages were often due to 
an excess of uric acid in the blood, and that this excess 
could be eliminated by the ingestion of mineral acids. 

Probably any mineral acid would prove efficacious, but 
there are two which suggest themselves as peculiarly effica- 
cious : hydrobromic acid, because of its sedative qualities, 
and nitromuriatic acid, because it is thought to limit the 
production of uric acid. 



DISEASES OF THE NOSE \\% 

The writer's experience has been Hinited to the effects 
of nitroniLiriatic acid, which lias been prescribed in doses 
of 5 to I o drops of the freshly prepared concentrated acid 
after meals and sometimes also at night. The dose should be 
diluted with one-half tumblerful of water, and the patient, 
after taking the medicine, should rinse out his mouth and 
swallow another half-tumblerful of water. 

The results of the remedy are apparent within forty-eight 
hours, and the relief of all hay-fever symptoms are usually 
sufficient to enable the patient to remain at home and attend 
to his ordinary business engagements in comparative 
comfort. If, however, a simple dose is omitted, some symp- 
toms of hay-fever will appear within the succeeding twenty- 
four hours. This is especially true if the remedy is not 
taken after the evening meal, as, under such circumstances, 
the patient usually wakes up the next morning \\\\\\ occluded 
nares and suffused eyes. 

Between the attacks of hay-fever measures should be 
adopted to improve the patient's general health and correct 
any abnormality of the interior of his nose. The practi- 
tioner, however, should not be too sanguine as to the 
beneficial results to be obtained by such measures, for it 
should be borne in mind that hay-fever not infrequently 
occurs in vigorous individuals the interior of whose noses 
present no gross abnormality except during the hay-fever 
season. 

There is, however, one condition of the nose that is 
apparently present in all individuals suffering from hay- 
fever, and that is the presence of hyperesthetic areas upon 
the respiratory portion of the nasal mucous membrane, 
which when touched with a probe cause sneezing and 
lacrimation. 

The hypersensitive condition of such areas may be 
destroyed one or two at a time, even during the hay-fever 
season, without adding to the discomfort of the patient by 
either palliative or radical methods. 

The palliative method consists of cocainizing the nose 
and touching the sensitive area with a lo per cent, solution 
of chromic acid applied by means of a cotton-tipped probe. 
The radical method consists in destro}'ing the sensitive area 



114 DISEASES OE THE NOSE, THROAT, AND EAR 

by means of the galvanocautery. A small cautery-knife 
should be selected, and the current should be sufficiently 
strong to instantly bring its tip to a white heat. After 
cocainizing the nose, the cautery tip is moved over the 
mucous membrane until a sensitive area is discovered. The 
current is then turned on for an instant and the cautery- 
knife withdrawn. Very little destruction of the membrane 
results, and should hemorrhage occur no undue haste 
should be used in controlling it, as the local depletion is 
beneficial rather than otherwise. 

Temporary relief may be obtained during the worst stages 
of the attack by spraying the nose with a weak alkaline I 
per cent, solution of cocain, and afterward with fluid vaselin 
as a protective. It is, of course, justifiable to use cocain 
during an office treatment, but cocain should not be pre- 
scribed for the patient's home use, as hay-fever victims are 
(often because of the neurotic temperament) the class of 
people most liable to contract the cocain-habit. 

As a home treatment the patient may spray the nose 
every hour or two, if necessary, with a solution of adrenalin 
hydrochlorate in the strength of i : 10,000 or i : 20,000. 
When the writer first began using this drug his results were 
not altogether satisfactory. Temporary relief was always 
obtained to a greater or less extent, but the use of the 
stronger solutions was always followed by a reaction similar 
to that of cocain solutions. Tlie results have been vastly 
better since very dilute solutions at frequent intervals have 
been employed. The solution should be freshly made and 
free from antiseptics, and for these reasons the drug is best 
prescribed for patients' use in the form of a small tablet 
which when dissolved in the proper amount of water forms 
a solution of the required strength. However, in many in- 
stances oily preparations are more efficient than watery 
solutions, and an ointment made up with lanolin and vaselin 
of a strength of i : 10,000 is of decided value. It is conve- 
niently dispensed in collapsible tubes, so that the patient 
can carry it about in his pocket and squeeze out from the 
tube from time to time the amount of ointment required. 
A piece the size of a pea may be inserted into each side of 
the nose every two hours by a brush or simply with the tip 



DISEASES OE EI IE NOSE I I 5 

of the little fin^^er. The head is then thrown baek until the 
ointment melts and distributes itself over the nasal mucous 
membrane. 

After the attack has subsided, all pathologic conditions 
of the nose should be removed, and the sensitive areas 
cauterized with a small galvanocautcry-knifc, so introduced 
that its flat surface will rest upon the sensitive areas and 
make a superficial burn. 

Professor Dunbar, of Hamburg, has prepared hay-fever 
antitoxins by the inoculation of horses with the toxins 
obtained from the albuminoid body found in the starch 
particles of pollen. The serum obtained from the horse is 
dispensed either in a liquid or dry form, and is designed to 
be applied to the mucous membranes of the nose and that 
of the eyes when required. 

The serum has been named Pollantin, and two forms are 
on the market, one prepared from rye pollen, especially 
used for spring and summer hay-fevers or ** rose colds," 
and the other, prepared from ragweed pollen, designed as a 
remedy for the hay-fever occurring in the late summer and 
fall. 

Dunbar believes that hay-fever is the result of a specific 
poison found in pollens, and his antitoxin is designed to 
immunize patients against pollen toxins when used previous 
to the hay-fever season and also to palliate the symptoms 
in cases where the disease has already made its appearance. 

When applied to the inflamed mucous membrane of the 
nose or eye pollantin produces a sensation of ease and 
comfort which persists for some time. 

Prognosis. — It is not unfavorable. Many cases completely 
recover. The patient should be kept under observation 
and occasionally treated for at least three years after an 
apparent cure to prevent the danger of a relapse. 

Nasal hydrorrhea is a disease characterized by a clear 
watery discharge from one or both nostrils as the result 
of some irritation or disturbance, either peripheral or 
central, of the vasomotor supply oi the nasal mucous 
membrane. 

Etiology. — In one class of cases the flow of fluid from 
the nose is perfectly passive and causes no inflammation. 



Il6 DISEASES OF THE NO^E, THROAT, AND EAR 

The phenomenon is probably due in such cases to a paresis 
of the nasal branches of the trifacial nerve, which exercises 
an inhibitory action upon the normal exosmosis of serum 
in the nasal mucous membrane. In a certain number of 
these cases the fluid discharged has been claimed to be 
cerebrospinal fluid, by some pathologic process a com- 
munication having been established between the nose and 
the subarachnoid space. 

In a second class of cases the flow of serum is accom- 
panied by great congestion and swelling of the Schneiderian 
membrane, and the phenomena are the result of an irritation 
of the vasomotor nerves. In this second class of cases 
the congestion and inflammation of the nasal mucous mem- 
brane and the consequent watery discharge are greatly 
increased by cold and by inhahng dust and other irritants. 
Indeed, the symptoms are somewhat similar to those of 
hay-fever. 

Symptoms. — In the first class of cases there is an almost 
constant dropping of a clear watery fluid from one or both 
nostrils. In the second class of cases the "discharge is 
more remittent in character, according to the amount of 
irritation of the Schneiderian membrane. 

Treatment. — In some cases adrenalin acts as a specific. 
A solution of the strength of i : 20,000 up to i : 1000 
should be sprayed upon the nasal mucous membrane 
sufficiently often to control the symptoms. From 2 to 5 
gr. of the extract of suprarenal capsule also should be 
taken every three hours, the patient being instructed to 
cease taking the remedy should disagreeable heart symp- 
toms manifest themselves. In some cases a cessation of 
the discharge occurs within a few days, and the use of 
the remedy should then be discontinued. 

As the cause of this disease is generally somewhat 
obscure, the treatment is necessarily expectant. The dis- 
charge terminates in some instances as abruptly as it began, 
almost without medication. Atropin sometimes is more 
useful than the extract of suprarenal capsule ; a pill con- 
taining 2-^Q- gr. may be given every three or four hours. 
In patients who can be trusted to barely moisten their 
mucous membrane with the spray from an atomizer coa- 



D/SKASKS OF THE NOSE I I 7 

taining J i^r. of atropin to i ounce of water, and not use the 
atomizer sufficiently often to cause [)Oisonous effects, a spray 
acts I'ar better tlian when atropin is taken by the stomach. 
The patients, of course, should be cautioned as to the very 
active nature of the poison and cautioned a^^ainst usin<r a 
sufficient amount of spray to reacli the pharynx. It 
sliould be borne in mind that 10 drops of the solution 
contain ^J-q gr. of atropin, and this amount (applied to the 
nose) never should be exceeded. Sometimes astringents 
applied locally answer a useful purpose, and an ointment of 
gallic acid (10 gr. to i ounce of vaselin with i or 2 gr. of 
menthol) may be prescribed with benefit. 

Nasal Hemorrhage. — llie synonyms ^x^ epistaxis ; rhinor- 
rhagia ; nosebleed ; hemorrhagia narium. 

Etiology. — It is an old saying that recurrent hemorrhage 
from the nose may be a warning, a remedy, or a disease. 

The bleeding may be the result of some disease of the 
blood, of which the most common are plethora, anemia, 
hemophilia, and the condition of the blood brought about 
by typhoid and the eruptive fevers. Diseases of the blood- 
vessels, the result of atheroma or syphilis, are predisposing 
causes, wdiile the increased blood-pressure resulting from 
Bright's disease and organic disease of the liver, heart, 
lungs, or kidneys are frequently early manifested by bleed- 
ing from the nose. Recurrent noseblood has hence been 
occasionally arrested by applying a blister over the liver, 
and in all cases the possibility of disease of some vital organ 
should be investigated and, if necessary, the proper remedy 
applied as a part of the treatment of nosebleed. 

No good observer probably has failed to be impressed 
with the very evident correlation existing in most of our 
domestic animals betAveen the nose and the sexual organs 
exhibited during the rutting season. Similar phenomena 
occasionally are observed in the human race, and many 
amusing stories are told in illustration. 

Erectile tissue occurs in but three portions of the human 
body: the nose and throat, the nipples, and the sexual 
organs. In the male, puberty is accompanied by a change 
of voice, and nosebleed is not uncommon at this time in 
either sex ; in the female, sometimes as a vicarious men- 



Il8 DISEASES OF THE NOSE, THROAT, AND EAR 

struation. Recurrent nosebleed is said to be aggravated 
by masturbation. 

Ulcerations and neoplastic growths within the nose are 
sometimes hemorrhagic. Angiomata, carcinomata, sarco- 
mata, and especially fibromata frequently bleed at the 
slightest touch. Severe and repeated nasal hemorrhage, 
when it occurs in a youth with a nasopharyngeal fibromata, 
is almost diagnostic of the latter. 

Traumatism is a frequent cause of hemorrhagia narium. 
If the blood flows from each side of the nose in equal 
amounts, it is somewhat suggestive of injury to the vault of 
the pharynx or even fracture of the base of the skull ; 
because hemorrhage from injury to the nose alone is usually 
unilateral. However, blood from the nose may be swal- 
lowed or drawn into the bronchi and afterward couorhed 
up or vomited in a manner suggestive of a pneumonic or 
stomachic origin of the hemorrhage. It is not always easy 
to make a diagnosis between bleeding from the vault of the 
pharynx and hemoptysis. 

The nasal vessels are not supported by a muscular cushion 
into which they may be crushed by a blow, but lie in more 
or less intimate contact with bone or cartilage and are only 
protected by extremely deHcate mucous membrane, and 
hence a slight injury is sufficient to cause hemorrhage, 
which is profuse and long continued, because the proximity 
of bone or cartilage prevents the ends of the severed vessel 
from contracting as readily as if they were imbedded in soft 
tissue. When sawing exostoses from the septum an artery 
within the bone is occasionally encountered ; and because 
the end of the vessel is held wide open by its attachments 
to the bone hemorrhage is invariably profuse and long 
continued. Such cases invariably require radical measures 
to control the flow. Fortunately, however, arteries within 
such growths are comparatively rare. Since the use of 
adrenalin solutions before nasal operations it is said that 
secondary hemorrhages after nasal operations are more 
common. The usefulness of this drug, of course, has its 
limitations. Its effects only penetrate a certain depth into 
the tissues and it, of course, has no effect on a vessel 
deeply imbedded in bone. 



DISEASES OF THE XOSE II9 

The proi^nosis of all forms of nasal hcniorrhai^c is f^cncr- 
ally favorable, but few fatal cases having been reported. 

Pathology. — The great vascularity of the nasal mucous 
membrane readily explains the great frequency of nasal 
hemorrhage. In most cases of spontaneous origin the 
bleeding is from the neighborhood of the septal artery — /. c, 
from the anterior part of the septum. Wounds resulting 
from surgical operations upon this portion of the nose 
frequently bleed profusely, although an artery is sometimes 
observed to " spurt " in the wound of an operation done 
further back upon the septum, while spontaneous bleeding 
may occur from posterior hypertrophies or adenoid vegeta- 
tions. In such cases the blood flowing downward into the 
fauces is expectorated and is frequently mistaken for a 
hemorrhage from the lungs. 

Treatment. — If after an operation severe hemorrhage has 
occurred, and it is known from what spot the bleeding 
occurs, a small mass of absorbent cotton should be tightly 
wedged within the nose over the bleeding vessel. 

Bleeding may occur from any portion of the nose, but it 
is most common from the anterior portion of the septum. 
In cases of recurrent nosebleed, if the alae be pulled to one 
side within a day or two after an attack, a small clot, a 
yellow spot, or a varicose condition of the veins upon the 
septum will mark the seat of the hemorrhage. Under such 
circumstances the patient should be directed to apply daily, 
by means of a brush, an ointment of gallic acid (10 gr. to i 
ounce of vaselin), and to avoid violently blow^ing the nose. 
Should the vessels be very numerous and varicose, this 
treatment will hardly suffice, and it will be necessary to 
destroy the vessels by a touch of the galvanocautery or 
chromic acid. It is not well to apply the galvanocautery or 
chromic acid too vigorously, as the cartilage of the septum 
has not much vitality, and too vigorous application of the 
acid may result in a perforation. Simply singe the mncoiis 
membrane lightly with the flat side of a small cautery-knife. 
A whitish spot upon the mucous membrane and the dis- 
appearance of the outHne of the vessel indicates that the 
burn will be effective. 

Occasionally recurrent nosebleed is the result of a small 



I20 DISEASES OF THE NOSE, THROAT, AND EAR 

ulceration or erosion of the mucous membrane of the anterior 
portion of the septum, generally in a hollow caused by a 
slight deviation of the septum or a cartilaginous spur or 
outgrowth within the nose. Because of the hollow upon 
the septal wall, mucus dries until the bulk becomes suffi- 
cient to extend above the hollow into the air-current, when 
it is dislodged by violently blowing the nose or by sneezing. 
Under such circumstances a minute portion of mucous 
membrane is carried away with the inspissated mucus and 
a hemorrhage occurs. Sometimes the hemorrhage occurs 
from dislodging such masses of mucus with the finger-nail. 
The patient should be cautioned against picking his nose, 
as under such circumstances the resulting ulceration be- 
comes deeper, until finally it extends entirely through the 
septum and a perforation results. 

Generally the formation of crusts and scabs can be pre- 
vented by frequent applications of carbolized vaseHn, but 
should this not suffice, the hollow in the septum must be 
eradicated by suitable operative procedure. The usually 
slight bleeding from anterior ulcerations, as it occurs from 
time to time, can be controlled by grasping the tip of the 
nose firmly between the thumb and finger, or the insertion 
of a small piece of ice within the naris, or by applying an 
ointment of adrenalin on absorbent cotton. 

This brings us to the consideration oi the control of 
severe nasal hemorrhage. In such cases such remedies as 
adrenalin are useless, because the flow of blood prevents 
their coming into contact with the mucous membrane and 
exerting their effects ; nor is it possible, in most instances, 
to accurately locate the bleeding spot and apply pressure to 
it directly. Usually the patient is found bending over a 
bowl upon his lap or he may be resting upon the bed in 
such a position that his head leans over its side so as to 
allow the blood to drip into a receptacle upon the floor. 
Have him at once sit erect, propped up with pillows, if 
necessary, with his head neither thrown back nor forward, 
and instruct him to hold a finger-bowl under his cJiin (not 
nose) to catch the flow of blood. 

This change of position takes off pressure from the veins 
in the neck and may be all that is necessary to stop the 



DlSEASl'lS OF 77//-: iVOSE I 2 I 

licniorrliagc. If this be the case, a httle pledi^^et o^ absorb- 
ent cotton, saturated with vaseHn, should loosely be in- 
serted within the naris to support the clot and prevent the 
patient breathinf^- throui^h that side of the nose. 

If in spite of the chan<^e of the patient's posture the 
blood should continue to flow, it will be necessary to apply 
pressure to the bleeding- vessel. This is most expeditiously, 
painlessly, and effectually accomplished by addini^ peroxid 
of hydrof^en to the clot within the nose, which hardens it 
and causes an increase of many times its ori^^inal bulk. 
Wrap a piece of absorbent cotton loosely about an Allen's 
probe so that it forms a cone 3 inches in length and i inch 
in diameter at its proximal extremity (Fig. 67). Thrust 




Fig. 67. — Method of making pressure-cone of cotton for the control of nasal hemorrhage. 
A piece of absorbent cotton {a) is frayed at each end into a thin edge, folded through the 
middle (dotted line a), and loosely wrapped about a nasal applicator in such a manner as 
to form a cone. This is dipped into peroxid of hydrogen and inserted within the nose. 



this, dripping with peroxid of hydrogen, along the floor 
of the nose until the pharynx is reached. Place the fore- 
finger-tip against the cotton within the nose and withdraw 
the probe, leaving the cotton in position supported by 
the finger-tip until the pressure caused by the ebullition of 
gas has somewhat subsided, then withdraw the finger and 
support the first pledget by means of a second plug of 
cotton saturated with peroxid of hydrogen. This is pressed 
firmly into the naris, especial care being taken that it firmly 
fills the space within the extreme tip of the nose, or blood 
will escape over the cotton plug. If required, a third or 
even a fourth plug of cotton may be used. 



122 DISEASES OF THE NOSE, THROAT, AND EAR 

When everything is ready, the whole maneuver can be 
executed in less than one minute, and the bleeding is 
instantly checked. If, after a minute or two, the fraction of 
a drop of blood shows itself oozing through the cotton, it 
should be coagulated by touching it lightly with Monsell's 
solution, and the process repeated from time to time if 
necessary. It is well, indeed, to smear the whole of the pre- 
senting surface of the cotton with the solution of the per- 
chlorid of iron, which dries with a Httle blood into a black 
impenetrable varnish, and allows no blood to trickle. 
Never apply any of the iron salts hisidc the nose to control 
hemorrhage, as they are extremely irritating and form a 
sort of sticky black sand difficult to remove. 

It should be remembered that it is not the peroxid nor 
the pressure of the cotton, but the pressure of the firm clot 
which forms within and about the cotton that checks the 
hemorrhage ; therefore the cotton should be wrapped about 
the probe with only sufficient firmness to enable it to retain 
its conic shape when passed along the floor of the nose. 
Within certain limits, the more loosely the cotton is wrapped 
the more peroxid it will take up and the more readily blood 
will enter its meshes. The conic shape of the mass 
facilitates its passage through the posterior naris, which, 
with the aid of a clot, it firmly closes. This method of 
controlling nasal hemorrhage is much less irritating than 
most others employed ; but at the end of five or six hours 
swelling of the mucous membrane will have occurred to a 
sufficient degree to render the packing within the nose 
somewhat uncomfortable, and it is generally advisable and 
safe to remove the outer plug. This should be done with 
extreme gentleness, avoiding any sudden pull or jerk. At 
the end of twelve or twenty-four hours the larger mass of 
cotton can often be removed with safety if done in a proper 
manner. Avoid removing pressure too suddenly or the 
hemorrhage will certainly recur and the packing will have 
to be replaced. It is well to have at hand a smaller cone 
of cotton saturated with peroxid to instantly replace that 
removed should this accident occur. Grasp the end of the 
mass of cotton to be removed with a pair of dressing- 
forceps and draw it forward \ inch, then wait five minutes. 



DISEASES OE THE NOSE 1 23 

Repeat tliis procedure at intervals of five minutes until 
the mass is coaxed, as it were, from the nose. If, dur- 
ing this process, a drop of blood shows itself, cut off 
with a pair of bandage-scissors that portion of the cotton 
already outside of the nose and press into the vestibule a 
little mass of fresh cotton saturated with i)eroxid. Vm con- 
tent to wait for an hour or so before again trying to remove 
the packing ; for, at any rate, you have diminished the 
pressure within the nose and rendered your patient more 
comfortable. If, however, you have succeeded in removing 
the whole of the cotton without the hemorrhage recurring, 
place a little cotton in the vestibule of the naris and allow 
your patient to rest for a half-hour or so before permitting 
him to blow out the clot — which should be done with great 
gentleness. It is advisable in all cases to remove the pack- 
ing from the nose at the end of forty-eight hours, as by that 
time it will be extremely foul smelling and there is danger 
of sepsis. If necessary to check the recurrent hemorrhage, 
the nose can be packed again with cotton saturated either 
with peroxid or cosmolin, which, next to peroxid, is prob- 
ably the best hemostatic for use within the nose. 

In most works on surgery an instrument called Bellocq's 
cannula is figured, by means of which the posterior nares 
may be plugged by drawing a mass of cotton or other 
material through the mouth behind the soft palate ; if at 
hand, this instrument may be used. A simpler plan is to 
insert a Eustachian catheter through the nose and pass a 
catgut suture string or well-waxed piece of stiff silk or liijen 
suture through it until its end appears in the fauces, when 
it may be seized by a pair of forceps and drawn out through 
the mouth. A piece of iodoform gauze should then be tied 
to the middle of the catgut string or waxed cord, and 
drawn up behind the palate into the vault of the pharynx 
in such a manner that one end of the string projects from 
the nose and the other from the mouth. The ends of the 
suture material may now be tied together so that the cotton 
plug is firmly held in position. If a Eustachian catheter is 
not available, a silk suture maybe tied around the eyelet of 
an ordinary soft-rubber urethral catheter, which is then 
passed through the inferior nasal chamber until the suture 



124 l^ISEASES OF THE NOSE, THROAT, AND EAR 

and catheter appear in the pharynx. However, plugging 
the posterior nares is seldom, if ever, necessary to check 
hemorrhage from the nose, but may be used where ether is 
administered to prevent blood flowing into the pharynx 
during an operation upon the interior of the nose. 

In hemophilia, after the nose has been packed with ab- 
sorbent cotton and peroxid, lo gr. of gallic acid or 20 
drops of fluidextract of ergot may be given every two hours. 
Very satisfactory results follow the use of chlorid of calcium, 
5 to 10 gr. every two hours may be given in capsule or 
dissolved in a little water. Some authors emphasize the im- 
portance of large doses, and as much as 40 gr. have been 
given once daily by the mouth or rectum. 

Recently Merck has introduced a new remedy for the 
control of hemorrhage called stypticin, said to be cotarnin 
hydrochlorate. A useful formula in nosebleed is : 

H: Stypticin, gr. xxiv ; 

Fluidextractum ergotse, " fc^vj ; 

Vin. ergotce, q. s. ad. fgij. — M. 

Sig. Of which a teaspoonful every two or three hours may be given until 
the hemorrhage ceases. 

TUMORS 

Nasal Polypus. — The most common growths to be found 
within the nose are myxoma or mucous polypus, fibroma 
or fibrous polypus, cyst, ecchondroma, exostosis, osteoma, 
papilloma, angioma, sarcoma, and carcinoma. 

Fibrous polypi differfromthe soft or mucous polypi simply 
because of the proportion of fibrous material each contains. 
Instead of being soft, gelatinous, and highly hygrometric, 
fibrous polypi are hard and fibrous. They usually have 
their attachment in the upper posterior portion of the nasal 
chambers. When attached to the junction of the nose and 
pharynx the fibrous tissue is so abundant that the result- 
ing tumor is a true fibroma almost as hard as bone. Naso- 
pharyngeal fibroma are extremely vascular, bleeding some- 
times at the slightest touch. Sometimes they hang down 
from the vault of the pharynx so as to be plainly visible 
through the mouth, and may send prolongations into the 
nose and all of the adjacent cavities, either bending around 



D/SI'lASES OF THE XOSE 



125 



obstiiclcs or crodini;" their way throuL^h thcin, ciilarL;iiii4 
llie nasal chambers, thinning" the bones, and broadenini; the 
bridge of the nose as tlie\' grow ; causing great deformity 
or what is sometimes called " frog face." Fibrous polypi 
are probably local hypertrophies of the mucous membrane 
and submucous tissues that have undergone fibrous change. 
Mucous polypi most frequently originate from the mid- 
dle turbinated region of the nose. Here the mucous mem- 
brane possesses low folds. It is thin, the subepithelial tis- 
sue loose and ^lbundant, and the erectile tissues scanty, 
'rhe mucous glands on the lateral surface of the middle tur- 
binates are numerous. 




Fig. 68. — A, Mucous polypi in the nose : B, anterior view of same, normal size (Sajous). 

As the result of chronic inflammation from any cause the 
normal folds of mucous membrane become edematous. This 
edema is favored by the dependent position of the parts 
until it is sufficient to develop into mucous polypi. The 
normal active glands of the middle turbinated region pre- 
vent the occurrence of edema, but when the glands cease 
to act as the result of degenerative changes edema results. 

Nasal cyst usually occurs as a large sessile bladder, filled 
with a thin, watery, mucous fluid, and attached to the inferior 
turbinated bone. 

Etiology. — Any long-continued irritation of the nasal 
mucous membrane may result in polypi. The most com- 
mon causes are ethmoiditis or defective nasal drainage, as 
the result either of bony ridges on the septum, a deviated 
septum, or of hypertrophies of the lower turbinated bone. 



126 DISEASES OF THE NOSE, THROAT, AND EAR 

Treatment. — Removal of the nasal polypi and the cause 
that produced them, in the manner described in the sections 
upon Ethmoiditis and Hypertrophic Rhinitis. The mere 
removal of the polypi is usually only the first step toward 
bringing about a cure of the nasal disease. Simple removal 
is usually followed by a relapse into the former condition. 
Therefore after the removal of the growth the surgeon 
should not be content until the parts from which they grew 
have firmly cicatrized, and it is well even then to see the 
case once every three months in order to ward off a possible 
relapse by snaring off promptly any small polypus or bud, 
which may be the first tendency exhibited toward a relapse 
into the former condition. 

As nasopharyngeal fibromata consist of fibrous tissue con- 
taining numerous large blood-vessels which (because of the 
hardness of the tissue in which they are imbedded cannot 
contract) when severed bleed profusely, such tumors cannot 
readily be severed by an ordinary snare. The best imported 
steel piano wire usually snaps during the attempt, or the 
snare may be twisted into a corkscrew shape if an attempt 
is made to tighten the wire by turning the screw of the 
instrument with a wrench. The growth is, however, readily 
removed by means of a galvanocautery snare with its red- 
hot wire. Relapses are common, although the disease 
generally attacks children, and there is a distinct tendency 
toward slower growth of the tumor as the individual 
advances in years. 

When the galvanocautery snare cannot be used, a pointed 
cautery-knife (Fig. 58) may be pushed through the tumor 
toward the center of the growth and heated while in situ. 
The current of electricity should be turned off as soon as 
the patient complains greatly of the heat and after an 
interval turned on again. This may be repeated several 
times before the cautery-knife is finally withdrawn from 
the growth, which should be done with gentleness and care 
w^hile the current is turned on in order to avoid hemorrhage. 
The procedure is less painful than electrolysis and results 
in a greater amount of shrinking of the growth. 

Nasal Papilloma. — Nasal papillomata are wart-like growths 
most frequently attached to the septum or inferior turbi- 



DISEASES OE THE NOSE 12/ 

nated bodies. Nasal papillomata arc i^cncrally abundantly 
supplied with capillaries and sonic of them bleed at the 
slightest touch. 

Treatment. — They should be removed with the snare and 
the place of their implantation touched with the c^aKano- 
cautery to prevent a recurrence. 

Nasal Sarcoma. — Sarcoma within the nose present the 
same pathologic characteristics as when present elsewhere. 
It may occur as a primary growth or result from the 
degeneration of fibrous polypi or papillomata. A nasal sar- 
coma is generally sessile and of a hght reddish color. In 
children they grow very rapidly and are prone to ulcerate, 
with the result of producing a fetid greenish or bloody dis- 
charge. Penetrating the surrounding structures, great 
deformity of the face often results. If growth occurs in an 
upward and backward direction, tinnitus, deafness, and 
severe pain are usually present, while death may occur from 
final involvement of the brain in the disease. 

Prognosis. — In children the growth ordinarily occurs so 
rapidly that an early fatal issue is to be expected, while in 
adults a slower growth makes early and complete evulsion 
practicable. The tumor will, however, return with increased 
malignancy if imperfectly removed. 

Treatuieut. — Early and complete removal of the growth, 
of course, presents the only chance of recovery. Palliative 
treatment consists in the use of detergent washes and 
anodyne applications. A 4 per cent, solution of the muri- 
ate of cocain may be applied on absorbent cotton to relieve 
pain and Formula 59 or 60 applied with the powder-blower 
for the same purpose and also as a disinfectant. Complete 
excision of the upper jaw^ on the affected side is necessary 
when the growth has attained any size, but even after the 
most complete operation relapses are the rule rather than 
the exception. In many cases the use of the ;i'-ray at 
least retards the progress of the disease. 

Nasal Carcinoma. — Carcinoma of the nose is of rare oc- 
currence as a primary affection, but may invade the nasal 
cavities from surrounding parts. It is usually of the epi- 
theliomatous or encephaloid type. 

Treatment. — Early and complete removal of the affected 



128 DISEASES OF THE NOSE, THROAT, AND EAR 

structures furnishes the only chance of a cure. Palliative 
treatment consists in cleanliness, nutrients, and the applica- 
tion of the ;r-ray to retard growth. 

DISEASES OF THE NASAL SEPTUM 

Deviation. — Normally, the septum is vertical, but after 
the seventh year deviations generally toward the left are 
somewhat frequent. Such deviations from the vertical only 
are considered pathologic when they interfere decidedly 
with nasal respiration or, by pressure upon -the middle or 
inferior turbinated body, cause pain or nasal reflexes. 

Etiology. — Traumatism is by far the most common cause 
of the pat]iologic deviations, the most frequent traumatism 
being a dislocation of the triangular cartilage and the 
anterior portion of the vomer from each other and their 
attachment to the nasal crests of the superior maxillaries. 
Under such circumstances the deviation is of the. so-called 
angular variety, because the dislocated horizontal edge of 
the septum projects into the obstructed nares as a sharp 
edge or ridge running back as far as the dislocation extends. 
The dislocation rarely or never involves the whole septum, 
because the posterior portion of the septum is defended 
from the effects of traumatism by its bony lateral walls. 
Rarely is more than the anterior third of the septum 
involved in a deviation, and it is therefore more exact to 
speak of a deflected area of a septum rather than a deviated 
septum. 

Between the edges of the dislocated bones and cartilage 
" provisional callus " is thrown out, which finally unites the 
separated edges with a firm bony or cartilaginous union, 
usually thicker than the normal septum, and hence the 
so-called *' hypertrophied angle " of a septal deviation. It 
will be seen that after the organization of the " provisional 
callus" the septum has notably increased in size, is redun- 
dant and too large to occupy a vertical position within the 
nose. 

It will be observed that a partial dislocation of the vomer 
from the nasal crests of the superior maxillaries necessi- 
tates a bending of the triangular cartilage toward the 
obstructed naris, and either a drawing downward of the tip 



DISEASES OE THE NOSE 1 29 

of the nose, a fracture of the cartila^rc^ or a separation of the 
cartihige from its articulation with the vomer, and in extreme 
cases also partly from its articulation with the perpendicular 
plate of the ethmoid. It is probable that in the majority of 
cases the latter takes place, as in most traumatic or anc^ular 
deviations there is usually considerable thickening at the 
posterior articulation of the triangular cartilage with the 
bones of the septum, the result of the deposit of provisional 
callus. It follows that in all deviations of the septum there 
is redundancy of the deviated area, both in the vertical and 
horizontal direction. According to the extent posteriorly 
of the dislocation of the septum from the superior maxillary 
may the deviation be described as vertical or horizontal. 
In comparatively rare cases a vertical deviation of the septum 
will involve so little of the septum anteroposteriorly as 
scarcely to admit the blunt end of a lead-pencil into the 
deflected area at the base of the septum. Such a deflection 
probably would result from a very rapid and violent bending 
of the tip of the nose to one side. 

Probably the larger number of deviations, so slight as 
not to be considered pathologic, are the result of a faulty 
development of the bones of the face. It is stated that 
adenoids and other causes of defective nasal respiration 
cause a high arching of the palate, and the septum, crushed 
between this abnormally high arch of the palate and the 
nasal bones, is bowed, as it were, out of the median position. 
During the development of the bony parts of the septum 
the floor of the nostril is not rigid, for the sutures between 
the maxilla, palate, and intermaxilla are wide and are filled 
in with soft tissue, on which the septum rests. Should 
ossification of this soft tissue occur too soon, it is stated 
that it would materially interfere with the growth of the 
septum, causing it to be deflected or crumpled. 

As a matter of fact, a comparatively large proportion of 
deflected septa are encountered, associated with a high arch 
of the palate, in which the deviation is pathologic and evi- 
dently not traumatic. Such deviations are curvilinear in- 
stead of angular, sometimes S shaped, and there is usually 
little or no thickening of the sutural lines. However, they 
rarely if ever involve the whole septum. 
9 



130 DISEASES OF THE NOSE, THROAT, AND EAR 

Asymmetric development of the two sides of the face, 
if it involved the nasal septum, would result in a bov/ing or 
deviation of the septum toward the larger side of the face, 
because the concave surface of a deviated septum is, of 
course, smaller than the convex surface. 

Pathology. — Septal deviations occur in almost endless 
variety. A simple classification is physiologic and patho- 
logic, angular, with or without hypertrophied tissue at the 
angle, round and S shaped, vertical and horizontal. The 
deviation usually involves little more than the anterior third 
of the septum, and almost never if ever the entire septum. 
In almost all cases of sharp, angular deviations hypertrophic 
changes occur at the apex of the angle, the narrowed 
nostril being still more obstructed by the bony ridge. 

Symptoms. — There is sometimes some deformity of the 
external nose, the tip of the nose being turned to one side 
or the bridge flattened. The degree of obstruction in the 
narrowed nostril is in proportion to the deviation of the 
septum and may amount to occlusion. Usually in such 
cases there is complete obstruction to inspiration from a 
valve-like action of the ala of the affected side, while expi- 
ration is somewhat free and unimpeded as the result of the 
blowing outward of the ala by the expired air. Naso- 
pharyngeal catarrh is usually present and is the direct 
result of the deviation. It will be observed that during 
inspiration a partial vacuum occurs posterior to the 
obstruction and consequent vacuum congestion ; that is, the 
decreased atmospheric pressure behind the obstruction en- 
gorges the blood-vessels of the mucous membrane by a 
species of suction. The vacuum congestion and conse- 
quent catarrhal inflammation frequently extend backward 
to the nasopharynx. Vacuum congestion also occurs 
within the dilated portion of the unobstructed nostril, and 
when chronic catarrh of the middle ear results, it is often 
the ear upon the side of the unobstructed nostril that first 
is affected. It might be objected to this mechanical theory 
of the causation of vacuum congestion back of a deflected 
area upon the septum that any partial vacuum resulting 
during inspiration would be counteracted by increased 
pressure during expiration. That this is not the case is due 



DISEASES OE 'J7/E A'OSE 



131 



to the fact that expiration is more deliberate and passive 
than inspiration and the valve-hke action of the ala referred 
to above. 

The amount of obstruction to nasal respiration resulting 
from a deflected septum is precisely the same as if the ob- 
struction resulted from an exostosis. When the obstruc- 
tion is complete for inspiration the individual loses one-half 
his nasal breathing space ; for what breathing space is lost 
in one nostril is not compensated for by increased breathing 
space in the other, because the unobstructed nostril is not 




Fig. 69. — Deviation of the septum and adjustment of the turbinated bodies (Coolidge). 



larger, either anterior or posterior to the obstruction, and 
hence will not transmit more air than if the septum were 
not deflected. 

In the dilated area of the unobstructed nostril the inferior 
and sometimes the middle turbinated bodies are frequently 
hypertrophied, probably as the result of the increased 
blood supply resulting from the decreased atmospheric 
pressure in the dilated area referred to above. As the 
result of such hypertrophy the breathing space within the 
dilated area may be reduced to normal limits (Fig. 69). In 



132 DISEASES OE THE A'OSE, THROAT, AND EAR 

the obstructed nostril the turbinated body may become 
atrophied from the pressure of the deflected septum. 
Should the deflection be so located as to cause pressure 
upon the middle turbinated body, pain and nasal reflexes 
are usually present. Fortunately, great deviation of the 
septum in this region is comparatively rare, and if present 
without obstruction to respiration the removal of a portion 
of the middle turbinal will prove an easier and more satis- 
factory operation than an attempt to restore the septum to a 
vertical position. Pressure symptoms may also be reheved 
in some cases by the removal of a portion of the septum 
by the saw. 

In some cases when the deflection is so slight as scarcely 
to be considered pathologic, erosions occur upon the septum. 
The inspissated secretions of such erosions being in a 
hollow of the septum, and hence not in the direct breath- 
current, are usually removed by the finger-tip or by 
violently blowing the nose. Usually some of the septal 
tissue is removed with the accumulation and hemorrhage 
results. The condition is a common cause of recurrent 
nasal hemorrhage. When such accumulations are removed 
by the finger-nail the erosion usually becomes deeper and 
deeper, until the individual literally picks a hole through 
his septum. 

The two factors interfering uitJi the success of operations for 
the correction of deviation of the nasal septum are redundancy 
and resiliency. The septum is too large to occupy a vertical 
position within the nose, and hence any operation, to be 
successful, must provide for the redundancy of the septum, 
both in the horizontal and vertical direction. The simplest 
method would seem to be a rectangular crucial incision 
through the center of the deviation. After such an incision, 
if the deviated area of the septum is brought into the median 
position, the edges of the four triangular flaps overlap, and 
thus the redundancy of the septum in both the horizontal 
and vertical directions is provided for. Redundancy of the 
septum is equally well provided for by multiple incisions 
through the septum, crossing each other at a common 
center, and by L, 1, U, and H incisions through the septum. 
This is far from being true as regards the resihency of the 



DISEASES OF THE NOSE 



133 



septum. Septal resiliency is best counteracted by means of 
a long, narrow, quadrilateral flap or by submucous com- 
plete removal of the cartilage and bone from the deviated 
area. 

It must not be supposed that because the deviated area 
of a septum is too large to be crowded into a position on a 
plane every point of which is equidistant from the lateral 
walls of the nose that, therefore, the tissues of the deviated 
septum are subjected to tension which, if released, would 
result in the deviated area of the septum assuming a normal 
vertical position as the result of its resiliency. On the 
contrary, if a deviated septum be dissected out from the 
nose, its deviated area does not change its shape, and if 
pressed into a position parallel to the rest of the septum, it 
immediately springs back into its original deflected position 
as soon as the pressure is released. It must not be 
imagined, as stated by some authors, that the resiliency of 
the septum is destroyed by in- 
cisions of any shape, mentioned 
above, as the resulting flaps 
when bent all tend to spring 
back into their former position. 

Resiliency is an inherent qual- 
ity of both the bony and cartil- 
aginous septum. However, if 
the bony portion be fractured, 
the broken bone remains in the 
position in which it is placed 
and the resiliency at the line 
of fracture is destroyed. The 
cartilage of the septum, on the 
other hand, is not readily frac- 
tured, but when bent at a right angle or more, its resiliency 
is greatly lessened for a considerable time. 

Operations for Correction of Deviation of the Nasal Septum. 
— BoswortJis Operation. — The simplest operation is that in- 
troduced by Bosworth (Fig. 70) — the removal of the hyper- 
trophied angle of the deviation with a saw. The operation 
is successful to the extent that it secures increased breath- 
ing space in the obstructed nostril, and the septum 




Fig. 70. — Vertical, transverse section 
through the anterior portion of the nose ; 
angular deviation of the septum, with 
hypertrophy of the tissues at the angle 
of the deviation. The dotted line in- 
dicates the direction" of the saw-cut for 
the removal of the obstruction. 



134 DISEASES OF THE NOSE, THROAT, AND EAR 

probably is brought more nearly into the median line as 
the result of the contraction of the resulting scar. 

IngaVs Operation. — Fletcher Ingals of Chicago makes an 
oblique incision through the membrane of the convex 
portion of the prominence. He then detaches the mem- 
brane a certain distance on each side of the cut from the 
underlying cartilage, exposing the latter. A triangular 
piece is then cut out, the base of the triangle being at the 
floor of the nose. Care should be taken to detach the 
cut piece from the lining membrane of the other cavity 
without tearing or cuttijig through it. The first incision is 
closed by stitches and the cartilage is pressed into line 
and supported by means of tampons. 

Sajous' Operation. — An operation formerly frequently per- 
formed in Philadelphia is described by Sajous as follows : 
" The least difficult operation and one which has always 
given me great satisfaction, in simple cartilaginous deflec- 
tions, is an incision through the protuberance, following its 
long axis. A smart hemorrhage occurs as soon as the 
incision is made, but it soon ceases. The end of the finger 
being introduced into the nostril, the septum is forcibly 
pushed beyond the center and maintained there by packing 
the previously obstructed nostril with carbolized oakum. 
The cut edges of the cartilage override each other and 
after a couple of weeks are firmly united." In this opera- 
tion the lower portion of the septum is practically im- 
movable by the finger, and hence the upper portion of the 
septum when brought into the median line hooks over the 
lower because of its redundancy, and to a certain extent is 
prevented from returning to its former deflected position. 
However, Sajous does not depend upon this support, but 
uses a pad of oakum. Seller described practically the same 
operation, but uses as a means of support a steel pin, which, 
while the finger is still in the nose, is thrust through the 
skin at the lower extremity of the nasal bones and then 
downward between the finger and the septum until its 
point is imbedded in the portion of the septum below the 
horizontal incision. After the finger is withdrawn from the 
nose, a few blows from a lead mallet serves to drive the pin 
firmly into the superior maxillary bones at their suture. 



DISEASES OE THE NOSE 1 35 

At the end of about ten days the steel pin becomes loose 
and useless as a means of support and has to be with- 
drawn. 

Watso7is Operation. — Watson describes his operation as 
follows: "I make an incision, which may be called a 
bevelled incision. The edge of the knife is directed upward 
and toward the opposite side, and carried through the carti- 
lage, but not the mucous membrane of the opposite side. 
The incision is made just at the crest of the deviation. Any 
vertical deviation is cut out, as before described (Ingals* 
Operation). The upper portion is then pressed over toward 
the other side, where it hooks itself on the lower, and is 
thus held in place." 

Watson's operation is a combination of the methods of 
Ingals and Sajous, and no detail of Watson's operation is 
original except, perhaps, that he more carefully bevelled 
his horizontal incision through the apex of the deviation. 
When the apex of the deviation is not hypertrophied, it 
would seem that in so thin a structure as the septum it is 
impossible to obtain any appreciable bcvcl^ and as bevelling 
does not increase the resistance to the septum assuming its 
former abnormal position, it is difficult to understand its 
importance. The preservation of the mucous membrane on 
the concave surface prevents the flap being bent at a suffi- 
ciently acute angle to destroy its resiliency. In the older 
operations of Sajous and Seller this same hooking of the 
upper fragment over the lower was found not sufficient to 
retain the parts in position, probably because of pressure- 
necrosis ; and support for a tediously long period by pins 
or plugs was found insufficient to secure invariably good 
results. 

Glcason's Operation. — The writer's method of operating 
for deflection of nasal septum is as follows : A U-shaped 
incision (Fig. 71) is made around the deviated area {a), 
which then becomes a quadrilateral flap, covering a hole in 
the septum ; a sort of trap-door with a spring hinge hold- 
ing it in a deviated position. This quadrilateral flap is then, 
with the finger-tip, pushed through the hole in the septum, 
which it covers, and its neck (c) is bent at the same time at 
a right angle. If the deviation area is of the horizontal 



136 DISEASES OF THE NOSE, THROAT, AND EAR 

type and extends far back along the septum, the neck of the 
quadrilateral flap will contain a considerable amount of bone. 
When the neck of the flap is bent at a right angle this bone 
will be fractured with a snap, often audible at a considerable 
distance. The resiHency of the bony portion of the flap is 
then completely destroyed, because fractured bone remains in 
the position in which it is placed. As a matter of fact it, to 
a certain extent, acts as a splint to retain the cartilaginous 
portion in a vertical plane, which it is usually impossible to 
fracture even by bending to a right angle. 




Fig. 71. — Diagram of author's operation. The traumatism originally causing the de- 
flection is practically reproduced by converting the deflected area of the septurn into a 
quadrilateral flap : a, Deviated area of the septum, surrounded by a U-shaped incision ; c, 
neck or base of the resulting quadrilateral flap ; b^ its inferior edge. 

However, by the thorough bending of the cartilage the 
resihency of the flap is diminished, for the time being, to 
the extent that it hangs without support in the vertical 
position, its redundant edge overlapping, without pressure, 
the edge of the hole in the septum, in front, below, and 
behind. 

The quadrilateral shape of the flap has much to do with 
its remaining in a vertical plane. In any cartilaginous sep- 
tal flap the resiliency tending to reproduce the original 



DISEASES OE EIJE NOSE 1 3/ 

deformity is proportionate to the width of the base {c) of the 
flap. In the triangular flaps used by Asch, Roberts, VVatson, 
and others the width of the base of the flap rapidly increases 
with the size of the flap. In the quadrilateral flap the base 
of the flap (Fii^. 71, c) is always of the same width as its 
G(k^g<^ [/?), and consequently, because of constantly increasing 
leverage proportionate to the length of the flap, in long, 
narrow, cartilaginous flaps, but very little support at its 
lower edge {/?) is required to maintain such a flap in the 
vertical plane. Tliis very important factor in the success 
of operations for the correction of septal deflections may be 
demonstrated by cutting flaps of various shapes in the side 
of a rubber ball, the resiliency of which may be compared 
to that of the cartilaginous septum. The main idea in 
devising this operation was to provide a better method of 
overcoming the resiliency of the septum than those then in 
vogue, and all other considerations were sacrificed to this 
idea. In most operations it is not septal redundancy^ but 
the neglect or the impossibility of providing for septal 
resiliency that causes failure. The resiliency of the septum 
is exerted for months upon septal flaps after apparent heal- 
ing, and often gradually reproduces, in part at least, the 
original deviation. It is impossible to judge of the success 
of an operation for septal deviation until at least six months 
have elapsed. Therefore it is best in most instances to 
slightly overcorrect the deviation. 

The technic of the writer's operation is as follows : Both 
sides of the septum are anesthetized by packing the nose 
with pledgets of absorbent cotton saturated with a 3 to 4 
per cent, solution of cocain. This is allowed to remain in 
contact with the parts for one-half to one hour in order that 
this weak solution of cocain may penetrate deeply into the 
tissues. The nostrils are sprayed with a I : 1000 solution 
of adrenalin. The line of incision is then painted by 
means of a cotton-tipped probe with a 10 per cent, solu- 
tion of cocain in order to produce profound superficial 
anesthesia. 

The field of operation is brought into view by means of 
the self-retaining speculum (Fig. 22), and a straight Sajous 
saw is introduced into the obstructed nostril, close to and 



138 DISEASES OF THE XOSE, THROAT, AND EAR 

parallel to the floor of the nose. The septum is sawed trans- 
versely until the saw has obtained a firm hold upon the tis- 
sues ; the direction of the sawing is then somewhat rapidly 
changed until it becomes nearly vertical, the saw meanwhile 
being carefully maintained in a position exactly parallel to 
the septum. A gush of blood from the unobstructed nos- 
tril indicates that the saw^ing has extended through the sep- 
tum. The saw is now partly withdrawn and its tip pushed 
through the cut into the unobstructed nostril. The anterior 
crus of the U-shaped incision is made by sawing upward with 
the tip of the saw. The posterior of crus is most quickly 
made by introducing a probe-pointed, double-edged knife, 
curved on the flat (Fig. 89), from the left nostril through 
the saw-cut. The index- finger-tip is then introduced into 
the right nostril. Finger and knife together reach the 
posterior limit of the deviated area, and the posterior crus 
of the U-shaped incision is quickly and easily made. 

If the deviation is toward the right nostril the operator 
wets his left forefinger in sterile w^ater, while if the deviation 
is toward the patient's left nostril the right forefinger, after 
being whetted, is introduced into the obstructed nostril, push- 
ing and, if necessary, lifting up the deflected area until it 
has been thrust through the hole in the septum which it 
covers. The operator's forefinger-tip is then carried up 
along the anterior and posterior crura of the U incision to 
make sure that the flap has completely cleared them ; the 
finger-tip is then thrust through the hole in the septum 
beneath the quadrilateral flap until the lateral wall of the 
nose in the unobstructed nares is touched. The finger is 
then pressed upward until the flap is bent at a right 
angle and any bone in the neck (Fig. 71, r) of the flap 
breaks w^ith an audible snap. This is of the utmost impor- 
tance, and in horizontal deflections the success of the opera- 
tion depends entirely upon the bending of the flap being 
thoroughly done. In vertical deflections too narrow to per- 
mit of the forefinger being used, the little finger should be 
employed. 

After the thorough bending of the flap it should hang in 
the formerly unobstructed naris without resiliency (Fig. 
73) ; and either Allen's tube or the writer's modification of 



DISEASES OE THE NOSE 



139 



the same should be dropped into the formerly obstructed 
nostril. Should any impediment to its free entrance into 
the nostril be encountered, it is probable that the U-shaped 
incision has been improperly made and has })assed tJiro^igJi 
instead of around some portion of the deviated area. This 
is usually the posterior portion of the deflected area, the 
posterior crus of the U-shaped incision being- made too far 
forward. An effort should be made to bring this deflected 
posterior edge of the incision into line with the finger-tip 
in order to admit of the easy introduction of the tube, and, 
failing in this, the end of the tube should be compressed by 
the fingers in such a manner as to permit of its easily being 




Fig. 72. — Vertical, transverse section 
through the anterior part of the nose ; angu- 
lar deviation of the septum without hyper- 
trophy of the tissues at the angle of the 
deviation. The dotted line indicates the 
direction of the saw-cut for forming the 
tongue-shaped flap covering the button-hole 
in the septum. 




Fig. 73. — Vertical, transverse section 
through the anterior portion of the nose, 
showing position of the septum alter the 
tongue-shaped flap has been thrust through 
the button-hole in the septum. After heal- 
ing has occurred, the parts at B are some- 
times abnormally thick ; but redundant tis- 
sue can readily be removed with the saw, 
Ordinarily it disappears spontaneously. 



passed beyond the obstruction. The tube should always 
fit loosely. Any great amount of pressure exerted by the 
tube becomes well-nigh intolerable within twenty-four hours. 
The tube serves to control the usually trifling hemorrhage. 
It is worn over night and the next day it is decided if its 
support is longer necessary. In rather more than 80 per 
cent, of cases of deviation of the nasal septum operated 
upon by the method described above no support whatever 
was necessary. 

The after-treatment consists in the patient presenting 
himself at the surgeon's office daily, in the meantime 




140 DISEASES OE THE NOSE, THROAT, AND EAR 

attending to his usual avocation if not too laborious. At 
each daily visit the parts are inspected and, if necessary, 
cleansed. At first the overlapping of the edges of the flaps 
resulting from its redundancy will 
appear excessive because of the 
swelling of the parts ; within a week 
or two this swelling will have disap- 
peared and also, apparently, much 
of the redundancy, because in trau- 
matic cases the redundancy is newly 
formed tissue, "provisional callus," 
and hence is readily absorbed. At 
Fig. 74.— Pins inserted for auy timc any rcduudaut thickening 

deviation of septum in Roberts' ti i j t- i. 1 

method of operation (Park). cau Tcadily bc rcmovcd, but unlcss 
the obstruction is so large in the 
formerly unobstructed nostril as to produce a decided imped- 
iment to respiration it is best to defer " trimming up " the 
redundant septal thickening until several months have 
elapsed after the operation, and the redundancy has 
thoroughly performed its function as a splint to prevent the 
quadrilateral flap of deflected area returning through the 
septum to its former deviated position. Rarely is any 
" trimming up " required. 

Roberts' Operation. — Roberts makes a long incision, 
oblique or horizontal, according to requirements, through 
the septum from back to front through the line of deviation 
or projection with a knife, and with a chisel through the 
bony septum if it be deviated. A pin is then thrust through 
the septum above and in front of the incision. By manipu- 
lation of the pin and finger introduced into the obstructed 
naris the upper or movable portion of the septum above 
the cut is brought into the middle line, and held in position 
by forcing the pin forward through the tissues in such a 
manner that it crosses the incision. A second pin is some- 
times introduced through the skin at the lower portion of 
the nasal bone parallel to the septum, in order to assist in 
retaining the parts in position. If the deflection of the 
septum is a general rather than an abrupt one, Roberts 
weakens the septum after the primary incision by multiple 
incisions with Steele's stellate punch, ** because the opera- 



DISKASJ'.S OJ' 7//JC A' USE 



141 



tion will be useless unless the incisions arc very free, so as 
to take away all resiliency of the cartilage." 

AscJi's Operation. — Until recently by far the most popular 
operation for deflection of the nasal septum, at least in 
America, is that devised by Morris I. Asch, of New York, 
described by him as follows : ** It occurred to me that 




Fig. 75.— Asch 's scissors. 

the vital point to attain in operating for this condition was 
to destroy the resilieiicy of the cartilage in such a way 
that when it should be forced back into its proper position, 
and held so for a proper length of time, the result would 
be a straightened septum without any loss of tissue and the 
re-establishment of the respiratory function of the affected 
nostril. 




Fig. 76. — Asch's compressing forceps. 



" The instruments required for the operation consist of a 
cutting forceps (Fig. 75), compressing forceps (Fig. 76), 
blunt and sharp separators (Figs. 77 and y%), to break up 
any adhesions which may exist between the convex portion 
of the deviated septum and the inferior turbinated body, 
and tubular nasal splints made of hard rubber. The cutting 
forceps or scissors are made in two sizes, They are power- 
ful instruments, curving outward from the point of junction 
and meeting again in front, one blade is blunt and narrow 



142 DISEASES OE THE NOSE, EH R OAT, AND EAR 

for introduction into the stenosed nostril, while the other is 
sharp with a triangular blade. Other scissors (Fig. 79) are 
made with the blades bent at a right angle, for use in devia- 
tions requiring an incision running downward. The com- 
pressing forceps used for straightening up the septum after 



Fig. 77.— Asch's separator, with blunt edge. 

incision are of two sizes with long and short blades respect- 
ively. The splints (Fig. 80) are curved hollow tubes made 
of vulcanite with perforations to prevent them slipping. 
An atomizer containing Dobell's solution is kept in a bowl of 



Fig. 



-Asch's separator, with sharp edge. 



ice to check any hemorrhage. The operation is performed 
under complete anesthesia of chloroform, ether, or Schleich's 
mixture, which has given good results in these cases. All 
the instruments are to be carefully sterilized and the nose 




Fig. 79. — Asch's scissors. 

washed out with an antiseptic spray before operating. The 
head of the patient being drawn backward over the edge of 
the table, so that blood will not enter the larynx, and the 
nostril illuminated either by direct or artificial light ; the 



DISEASES OE 77/E NOSE 1 43 

blunt separator is introduced into the deviated side, so as to 
break up any adhesions that may exist and to ascertain the 
presence of any bony obstruction posteriorly, should such be 
found, the sharp separator can be used or an ordinary small 
bone chisel. The scissors are now introduced parallel to the 
floor of the nose, the sharp blade being in the concavity and 
the blunt one over the line of greatest convexity of the devia- 
tion ; it is important that the blades should be at right angle 
to the septum at the place of incision, otherwise the blades 
may override and the scissors fail to cut through. The blades 
being firmly closed, the sharp one cuts through the cartilage 
into the opposite side with a distinct snap. The scissors are 
then opened and completely withdrawn. They are imme- 
diately reintroduced in the same manner as before, with the 
blades pointing this time in a vertical direction, crossing the 
line of the first incision as near as possible at right angles 




Fig. 8o. — Mayer's tube. 

and at its center; the scissors are now closed and the second 
incision made, after which the scissors are opened and with- 
drawn. We have thus four segments as the result of the 
crucial incision. The operator now introduces his finger 
into the stenosed nostril and forcibly pushes the segments 
into the concavity of the opposite side, effectually breaking 
them at their base. The finger should be pushed through. 
This part of the procedure must be done thoroughly and 
carefully, for on it depends the success of the operation. 
If the segments are thoroughly broken at their bases the 
resiliency of the cartilage is destroyed and the deviation 
cannot recur. The compressing forceps are now introduced, 
one blade in each nostril, and the septum compressed in 
order to straighten it still further and to force the broken 
segments to more completely override each other. The 
iced Dobell's solution in the atomizer is now sprayed into 



144 I) IS EASES OF THE NOSE, THROAT, AND EAR 

the nostrils in order to check the bleeding, and the sterilized 
tubes introduced, a snugly fitting one into the side previously 
stenosed and a smaller one in the opposite. These serve- 
to prevent hemorrhage and to hold the septum in its new 
position. This completes the operation, which, in ex- 
perienced hands, should not occupy over five minutes. The 
patient is now placed in bed, iced cloths applied externally, 
and a cold antiseptic solution sprayed into the nostrils every 
half-hour. Twenty -four hours after operation the tube in 
the non-stenosed side is removed and not replaced, the 
spray and compresses being continued. Twenty-four hours 
later the tube in the opposite side is removed, thoroughly 
cleansed and sterilized, the nose is sprayed and cleansed 
and the tube replaced, cocain being used if necessary. The 
same tube should be reinserted unless it proves too large 
for comfort, in which case the next smaller size can be used. 
This tube must be taken out and cleansed every day by the 
surgeon while the patient remains in bed, which he should 
do for at least four days. At the end of this time the 
nostril is less sensitive and the patient should be able to 
extract and reintroduce the tube himself This is to be 
done every day for four weeks, coming once a week to the 
surgeon for observation, and at the end of the time the tube 
is permanently withdrawn, the septum having now become 
sufficiently solid to remain in its new position without 
support. It sometimes happens that the lower segment 
remains thickened after the tube has been withdrawn and 
projects into the nasal cavity ; this can easily be rectified by 
the electrotrephine or galvanic cautery, though if left to 
itself the thickening will eventually disappear." 

Kylcs Operation. — Kyle, of Philadelphia, makes two 
horizontal parallel incisions through the deflected area by 
means of Fetterolf 's triangular file (Fig. 8i), not involving 
the mucous membrane of the convex side of the septum, 
and brings the enclosed area into the median line by means 
of finger or forceps. Fetterolf has modified Kyle's opera- 
tion by the use of triangular files (Figs. 8i, 82). The 
operator's finger is inserted into the unobstructed nostril 
and parallel incisions made with the sharp-edged file (Fig. 
81) on the convex surface of the septum, the finger of the 



DISEASES OE THE NOSE 1 45 

operator readily detecting when the cartilage has been cut 
through to the mucous membrane. If desirable more car- 
tilage can be removed by means of a file truncated on its 
edge (Fig. 82), in order to avoid wounding the mucous 
membrane of the convex side of the septum. Two — some- 
times three — parallel incisions are made, one just below, 
one through the center, and one just above the deviation. 
Sufficient cartilage is removed to completely destroy the 
resiliency of the septum. 



Fig. 81. — Fetterolf's sharp-edged triangular fi 

Roc's Operation. — Roe, of Rochester, breaks the bony 
portion of the septal deviation by means of specially 
constructed forceps of several sizes, the male blades of 
which fit into a fenestrum in the female blade. By means 
of these forceps the bone is not mer.ely bent, but is actually 
fractured, and the resiliency of that portion of the septum 
destroyed. 

''Windoiv resection'' of tlic deviated area, advocated first 
by Ingals (see Ingals' Operation) and later by Krieg, has 
many advocates. Killian removes the cartilage and bone 



Fig. 82.— Fetterolf's truncate-edged triangular file. 

of the entire deviated area, preserving the mucous membrane 
of both sides of the septum. The technic of the operation 
and the instruments have been greatly improved by 
Ballenger, who describes his method as follows : 

" The technic of the operation," according to Ballenger, 
" is after the Menzel-Hajek method with the exception of 
the removal of the cartilage. In the Menzel-Hajek opera- 
tion the cartilage is removed piece by piece wdth punch 
forceps ; whereas, by my method it is removed in one piece 
with one cut of the sw^ivel knife. The time required for the 
removal of the cartilage after the mucoperichondrium has 
been elevated need consume but a few seconds ; whereas, by 
10 



146 DISEASES OF THE NOSE, THROAT, AND EAR 

the Menzel-Hajek method it takes from a i^w to several 
minutes for its removal. Using a special knife (Fig. 83) 
I make a curved incision in the septal mucosa of about i 
inch in length, beginning near the floor of the nose and 
curving forward and upward, as high as I can, through the 
vestibule of the nose and about \ inch posterior to the 



Fig. 83. — Ballenger's septum knife. 

anterior margin of the cartilage. I have not found it 
necessary or expedient to make the incision on the convex 
side of the septum, as is commonly recommended ; but I 
find it advisable to make it on the left side of the septum 
regardless of whether this is the convex or the concave 
surface. I do this because it is convenient to use the knife 



Fig. 84. — Hajek's semisharp elevator. 

with the right hand while the forefinger of the left is inserted 
into the right nostril. Having made the curvilinear incision 
through the mucoperichondrium on the left side of the 
septum, I next resort to the semisharp elevator of Hajek 
(Fig. 84) to elevate the anterior portion of the mucoperi- 
chondrium from the septum, after which Hajek's blunt 



-Hajek's blunt elevator. 



elevator (Fig. 85) should be used. The semisharp elevator 
should only be used to start the elevation, as to continue 
its use might result in a perforation of the mucous mem- 
brane, whereas the dull elevator can be used with great 
rapidity without danger of perforation. 



DISEASES OF THE NOSE 



H7 



" The next step in the operation consists in carrying the 
anterior curviHnear incision of the mucosa through the 
septal cartihige to the perichondrium of the 
opposite side. This is done with a small 
bistoury (see Fig. 83), the forefinger of 
the left hand being inserted into the right 
nostril to detect when the cartilage is com- 
pletely incised. After one has had con- 
siderable experience in the incision of the 
cartilage with a knife he may not find it 
necessary to introduce the finger into the 
opposite nostril, as he can readily appreci- 
ate when he is through it by the sense of 
touch or by the resistance felt with the hand 
holding the knife. The semisharp elevator 
of Hajek may be used to perforate the 
cartilaginous septum along the line of the 
curvilinear incision by rubbing it to and fro 
in the mucoperichondrial incision, the in- 
dex-finger of the left hand being inserted 
in the right nostril to exert counter-pres- 
sure and to detect by the tactile sense 
when it is completely broken through. 

" The incision through the cartilage hav- 
ing been made by either of the above 
methods, the semisharp elevator should be 
inserted through it with the flat side turned 
so as to he against the right side of cartil- 
aginous septum, and while in this position 
it should be moved up and down and insin- 
uated between the cartilage and the muco- 
perichondrium of the right side. To facili- 
tate this procedure the tip of the nose 
should be turned toward the patient's right 
side, thus exposing the curvilinear incision 
through the mucosa and cartilage, and mak- 
ing it possible to introduce the semisharp 
elevator on a plane parallel with the sep- 
tum. After this side is started, the dull elevator is used to 
complete the separation. Care should be taken to lift the 



Fig. 86. — Ballenger's 
swivel knife. 



148 DISEASES OF THE NOSE, THROAT, AND EAR 

mucoperichondrium from the entire deflected area, as to 
fail to do so makes it impossible to remove a sufficient 
amount of the cartilage. 

" The mucoperichondrium on both sides of the septum 
now being elevated, the prongs of the swivel fork are intro- 
duced through the curvilinear incision, one prong being on 
the right side of the septum and the other on the left. The 
instrument should now be directed backward parallel with 
the floor of the nose until the posterior limit of the cartilage 
is reached, when it should be directed upward and forward, 
following the outline of the anterior end of the perpendicular 
plate of the ethmoid to the bridge of the nose, when it 
should be pulled downward parallel with the cavity, the 
triangular blade resting upon the concavity of the ridge of 
the nose to the upper extremity of the curvilinear incision. 
In this way almost the entire cartilaginous septum except 
the anterior tip, which is left to support the tip of the nose, 
is remov^ed. The excised cartilage should now be seized 
with a pair of dressing-forceps and removed through the 
curvilinear incision. The cartilage thus removed is usually 
roughly triangular in shape, the acute point of which 
represents the posterior end of the cartilage." 

For the removal of a portion of the bony septum Freer's 
modification of Griinwald's punch-forceps may be used. 
With the instrument, according to Freer, bone \ inch thick 
can be bitten in two. With this instrument the bony sep- 
tum may be removed piece by piece. After removal of 
the cartilage the nasal cavity and wound are cleared of all 
debris. The mucous membrane is brought into as near 
normal apposition as possible and covered with gauze 
previously dipped in albolene. Over this a very light pack- 
ing of bichlorid gauze is placed. On the opposite side of 
the nose a light packing of gauze may be placed as a 
support to the membranous septum. The dressing on both 
sides may be dispensed with the following day. The nose 
should be cleansed twice daily with Dobell's solution until 
recovery is complete. 

Lee Maiden Hurd says of the operation (Manhattan Eye, 
Ear, and Throat Hospital Reports, March, 1906) : " Inas- 
much as the operation has come to stay, it will in time 



D/SEASKS OF THE NOSE 1 49 

probably supplant the crushing; operations of Asch, Glcason, 
Roe, and others entirely. However, it is a much more 
difficult operation to master thorou^^hly than the above 
mentioned, and in consequence of these technical difficulties 
it may not be as universally employed for some time as its 
merits justify." 

In the older operations solid plugs of vulcanite or ivory 
were sometimes used. Sajous employed a plug of oakum, 
and pledgets of iodoform gauze or absorbent cotton are 
sometimes employed at the present time. Roberts employed 
steel pins to hold the septum in position after operating 
(Fig. 74). The pin had a square head. Seiler used an 
ordinary darning needle ; Gibbs, a pin with a pear-shaped 
head; and Watson, a pin with a spear-shaped point, the 
other end bent into a ring and protected by a piece of thin 
rubber, through which the pin was thrust before being used. 



Fig. 87. — Kyle's malleable nasal tube. 

Steel pins may be allowed to remain in the tissues for about 
ten days ; after that time they become so loose that they 
have to be removed. They cause a certain amount of 
sloucrhinor of the cartilao-e, which aids in reducing- its 
resiliency. 

Asch and Meyer employ vulcanite tubes (Fig. 80). 
Berens, of New York, used a hollow olive-shaped splint of 
cork, varnished with iodoform collodion. Kyle employs 
the tube shown in Fig. 87, made of soft malleable metal, so 
that it readity can be bent or cut into a shape suitable for the 
nasal condition present. Harrison Allen devised a brass 
silver-plated tube, which differs from the other tubes 
inasmuch as it is prevented from slipping from the nose 
by the upper portion of its distal extremity, which rests in 
the hollow space at the tip of the nose. The writer has 
slightly modified the shape of this tube, and had it made in 



I50 DISEASES OF THE NOSE, THROAT, AND EAR 

three sizes, of the same soft malleable metal employed in the 
Kyle tube. It readily can be cut with a knife or scissors 
or pressed by the fingers or the handle of an instrument 
to meet any unusual nasal condition present, should such 
modification of its shape be necessary in any particular 
case. 

Congenital Occlusion of the Nares. — Congenital occlusion of 
either the anterior or posterior nares, usually unilateral, is 
a somewhat rare condition. When the posterior nares are 
occluded generally it is the result of a bony outgrowth 
from the floor of the nose. The anterior naris may be 
occluded as the result of faulty development or adhesions 
during embryonic life. 




Fig. 88. — Gleason's nasal tubes. 

Symptoms. — The symptoms are those of occlusion from 
any other cause. When the occlusion is posterior, there is 
a discharge of mucus from the nose upon the lip and the 
patient is unable to cleanse the nostril by blowing the nose. 
Aural symptoms are sometimes present when the obstruc- 
tion is anterior. 

Diagnosis is made by inspection. Anterior obstructions 
are readily seen, and those which are posterior may be 
observed in the rhinoscopic mirror. A rough estimate of 
the thickness of a posterior obstruction can be made with 
an Allen's probe, the end of which is wrapped with cotton 
and saturated with a 4 per cent, solution of cocain. This is 
introduced into the obstructed naris until the obstruction is 
reached, and the distance compared with that to the pos- 
terior edge of the septum on the unobstructed side. 

Anterior obstructions are usually thin and web-like. 
Posterior obstructions usually have a thickness of not over 
i inch. 



DISEASES OE THE NOSE I5I 

Treatment. — It is comparatively easy to break clown nasal 
obstructions, either anteriorly or i)osteriorly ; but as they 
almost invariably recur unless prevented from doing so by 
a somewhat tedious after-treatment, the wisdom of operat- 
ing in young children unless very docile is worth consider- 
ing. When only one side is affected and causes but little in- 
convenience, the operation in young children should be 
postponed until the child has arrived at an age to appreciate 
the advantage to be derived from the after-treatment. 

Anterior obstructions are excised with a knife or scissors 
and a pewter tube (Fig. 88) of suitable size and shape 
inserted. This is removed and cleansed daily after the 
operation until the parts have completely cicatrized. 

Posterior bony obstructions are removed with the guarded 
electric drill or burr (Fig. (y^, either under ether or, as the 
operation is not very painful, under cocain anesthesia. If 
ether is employed the tip of the forefinger of the operator's 



Fig. 89. — Seller's septum knife. 

left hand is inserted into the posterior naris from the 
pharynx, to serve as a guide to the parts to be removed by 
the drill and to prevent injury to the surrounding structures. 

The after-treatment consists in daily cleansing the parts 
and the passage of bougies until cicatrization is complete. 
However, in spite of every precaution, the posterior naris at 
the site of the operation frequently becomes again occluded 
by a thin cicatricial membrane. Should such a membrane 
form, it possesses but little vitality, and in 2 cases observed 
by the writer was destroyed by piercing it in two or three 
places with a small galvanocautery-knife ; after which it 
did not recur. 

Dislocation of the Columnar Cartilage. — The so-called 
columnar cartilage is the inner plate of the lower lateral 
cartilage of the nose (Fig. 50), a small strip of cartilage lying 
parallel with the lower border of the septum, the purpose 
of which is to act as a support to the columna. 

Dislocation of the columnar cartilage, as ordinarily seen, 



152 DISEASES OF THE NOSE, THROAT, AND EAR 




consists of the displacement laterally of the distal extremity 
of the septum in such a manner as nearly to occlude the 
affected nostril (Fig. 90). 

Treatment. — The mucous membrane should be incised 
over the most prominei^t part of the deformity in such a 
manner as to allow the excision of a sufficient amount of 
the septal cartilage to restore the patency of the affected 
nostril. It is not generally necessary to suture the edges 
of the incision after the excision of the cartilage. No 
after-treatment is required. 

Hematoma of the septum is 
an extravasation of blood be- 
neath the mucous membrane 
of the septum, generally the re- 
sult of traumatism. It presents 
itself as a blood-red tumor, 
sometimes large enough to ob- 
struct nasal respiration. 

Prognosis. — The blood may 
be absorbed, or inflammation 
may occur and an abscess re- 
sult. 

Treatment. — If the amount 
of blood is large, an incision 
should be made to allow it to 
escape. 
Abscess of the Septum. — Etiology. — Abscess of the septum 
may result from traumatism, syphilis, or phlegmonous in- 
flammation of the septum. 

Symptoms. — There may be the history of a chill, followed 
by fever, as in abscess elsewhere. Upon inspection the 
nose is found to be obstructed by a soft, fluctuating tumor 
of the septum. Generally the septum is soon perforated, 
so that the tumor becomes bilateral. 

Treatment. — Early evacuation of the pus to prevent exten- 
sive destruction of the parts involved in the inflammation 
and hasten resolution. The incision through the abscess 
should be sufficiently free to allow of syringing with subli- 
mate solution if deemed necessary, and the patency of the 
opening should be maintained by the daily passage of a 




Fig. 93. — Dislocation of the columnar 
cartilage of the nose into the right nostril 
(Bosworth). 



D/SKASKS OF TIIK NOSE I 53 

probe or the introduction (;f a drain of iodoform i^auze. If a 
sec[ue.struni of cartilaj^eor bonef(;rni it should not be rernoved 
until eompletely separated, and extreme care should be 
exercised to prevent injuring the mucous membrane of both 
sides of the septum, or a perforation of the septum will be 
present when the healinf^ process is complete. 

Submucous infiltration of the septum is a comparatively fre- 
quent accompaniment of chronic rhinitis, consisting of an 
edematous tumefaction situated on each side of the septum, 
generally at its posterior portion. 

Treatment. — If nasal respiration is obstructed, the masses 
may be scraped from the septum with the nasal curet or 
cauterized with the galvanocautery. 

Injuries and Deformities of the Bony Tramework of the 
Nose. — By far the most common result of nasal traumatism 
is dislocation of a portion of the septum from its attach- 
ment to the nasal processes of the superior maxillary bones. 
The dislocation is often overlooked at the time the injury is 
received because of the profuse hemorrhage. If a surgeon 
is consulted, his efforts usually are directed to controlling 
the flow of blood ; and often he does not again see his 
patient for some days or weeks. Then the patient states 
that he can breathe through one nostril, but not through 
the other. 

Inspection of the nasal cavities shows a bulging area of 
septum in the obstructed nostril, corresponding to a con- 
cavity upon the septum in the opposite nostril. If seen 
within a week or two of the injury, the parts should be 
anesthetized by placing pledgets of absorbent cotton 
saturated with a 4 per cent, solution of cocain. The surgeon, 
after removing the cotton pledgets, wets with sterile water 
the forefinger of his right hand if the patient's left nostril 
is obstructed, or the left forefinger if the obstruction is in 
the patient's right nostril. With the palmar surface toward 
the septum and a slight boring motion the surgeon's finger 
is guided along the floor of the patient's nose. As the 
finger advances, pressure from the finger-tip readily forces 
the dislocated septum into a position median to both sides 
of the nose, after wdiich the tube (Fig. 88) is inserted to act 
as a splint. 



154 DISEASES OF THE NOSE, THROAT, AND EAR 

Flattening of the Bridge of the Nose or Saddle-back Nose. 
— A common result of nasal traumatism is fracture of the 
nasal bones at the root of the nose. The distal fragments 
are rotated outward on their long axes and depressed, pro- 
ducing a broadening and flattening of the bridge of the nose. 
When only one nasal bone is fractured, the tip of the nose 
is usually turned to one side as the result of dislocation of 
both lateral upper shield cartilages and the septum. 

If the case is seen soon after the injury the displaced 
nasal bones are brought into position one after the other 
by means of Adams' forceps (Fig. 91), one blade of which 
is inserted into the nostril, so that the nasal bone can be 
grasped between the blades and lifted and turned into the 
normal position. When both nasal bones are in place they 
are supported by a splint fashioned from gauze and collo- 
dion placed on the outside of the nose. If the septum is 
deviated at the time of the injury it is brought into the 
median line and the tube (Fig. ^%) inserted into the formerly 
obstructed nostril. 




Adams' septum forceps. 



Old cases of saddle-back nose may be operated on by 
the following method : To prevent the flow of blood into 
the pharynx during the operation, the posterior nares are 
plugged with gauze by the aid of Bellocq's cannula. The 
patient being etherized, an incision is then made through 
the skin into the nose close to the septum at the extremity 
of the nasal bones. One blade of the writer's nasal cutting 
forceps (Fig. 92) is then thrust into the nose and the other 
pushed under the skin in such a direction that when the 
forceps is closed and locked its edges bite into the suture 
between the nasal bones and septum. When in position 
the blades of the forceps are locked, and by slightly rotat- 
ing the instrument backward and forward the suture parts 
with an audible snap. The forceps are then withdrawn and 



DISEASES OF THE NOSE 155 

the procedure repeated on the other side of the septum. 
An incision is then made at the anterior-inferior extremity 
of the nasal bone of one side, and one blade of the forceps 
introduced into the nose and the other blade beneatli the 
skin. The blades are locked as nearly as possible into the 
suture between the nasal bones and the nasal processes of 
the superior maxillary. Backward and forward rotation of 
the forceps causes the bone to part with a snap, and all 
resistance to the partial rotation of the forceps ceases. The 
procedure is repeated on the other side of the nose. The 
nasal bones are now severed from their attachments except 
at their base, which also is sometimes fractured by the 




Fig. 92. — Gleason's nasal bone-cutting forceps. 

movements of the forceps. One blade of an Adams forceps 
is now inserted into the naris and the loose nasal bone 
grasped between the flat blades of the instrument. Ordi- 
narily it is easy to rotate the bone upon its long axis in such 
a manner as to increase the height of the bridge of the 
nose, and at the same time the bridge of the nose is made 
more narrow by pressing the anterior-inferior edge of the 
nasal bone medianly toward the septum. The same pro- 
cedure is. applied to the opposite nasal bone. Steel pins are 
now inserted in the space between the nasal bones and 
the nasal processes of the superior maxillary bones and 
thrust transversely downward through the septum until 
their points rest upon the floor of the opposite nostril. 



156 DISEASES OF THE NOSE, THROAT, AXD EAR 

A few blows from a lead mallet serve to firmly fix them in 
position. The pins are then cut off \ inch above the surface 
of the skin. They cross where they pass through the 
septum, and hence assume an X shape, the nasal bones being 
retained somewhat firmly in position by the upper V of the 
X. The steel pins should be of considerable size, the 
ordinary darning needles sold in dry-goods' stores answering 
a very good purpose. In about ten days to two weeks they 
become loose in the tissues and it may be necessary to 
remove them, after which the bridge of the nose is sup- 
ported by a splint fashioned from gauze and collodion, and 
worn until the bones are firmly united. Should it prove 
impossible to separate the bones at the suture between the 
nasal bones and the nasal processes of the superior maxil- 
lary subcutaneously by means of the cutting forceps (Fig. 
92), an incision is made through the skin down to this 
suture and the bones separated with a chisel. 



Fig. 93. — Harmon Smith's screw-syringe for the subcutaneous injection of paraffin. 

Paraffin Prothesis. — When the bones of the bridge of the 
nose are destroyed or greatly distorted as the result of 
syphilis or other cause, satisfactory results follow the injection 
of paraffin beneath the skin into the cellular tissue of the 
nose. A special paraffin is prepared by mixing with 
ordinary paraffin white vaselin until the mixture melts at 
about 1 10° F. (Formula 96). This special paraffin is readily 
injected at ordinary temperatures through a needle but little 
larger than an ordinary hypodermic needle by means of the 
screw-syringe (Fig. 93). As the screw is turned the paraffin 
exudes from the end of the needle in a worm-like thread, 
readily compressible between the thumb and finger. The 
paraffin, having been melted, is drawn into the barrel of 
the syringe, which it completely fills. The end of the 



n IS EASES OF THE NOSE I 57 

syringe where the needle is screwed on is then closed with 
a screw-cap to prevent the escape of the paraffin, and the 
syringe with the paraffin it contains and the needle to be 
used are dropped into the sterilizer and most carefully 
sterilized in boiling water. The syringe is then allowed to 
cool and the needle screwed into place ready to use. 

The patient requires no special preparation other than 
washing the skin of the nose with green soap, alcohol, and, 
finally, corrosive sublimate solution (i : looo). 

The end of the needle is inserted near the tip of the nose 
and thrust through the subcutaneous cellular tissue slightly 
beyond the deformity. Before beginning the injection the 
operator should assure himself that the point of the syringe- 
needle lies in the cellular tissue and hence is freely movable. 

The screw of the instrument is slowly turned, and as the 
paraffin is pushed out through the needle it presses aside 
the cellular tissue and infiltrates it. The paraffin is molded 
into shape by the thumb and finger of the operator to the 
exact shape desired. The syringe-needle is then w^ithdrawn 
a short distance, and more paraffin thrown into the cellular 
tissue, which is molded into shape ; and so on, until the 
needle is finally withdrawn from beneath the skin of the 
nose. Before this is done care should be taken to break 
the thread of paraffin at the needle's point, so that paraffin 
will not be drawn iiifo the skin as the point of the needle is 
withdrawn through it. The thread of paraffin is readily 
broken by grasping the point of the needle through the 
skin and rotating the instrument inmiediately before the 
needle is withdrawn. 

Not more than 20 minims of paraffin should be injected 
at one sitting, in order to avoid injurious pressure and the 
cutting off of the circulation sufficiently to cause sloughing. 
It should be borne in mind that the operation is so simple 
and painless that it can be repeated as often as necessary 
to accomplish the desired result, so that it is foolish to 
attempt too much at one sitting. 

Little or no swelling follows the injection, and the after- 
treatment consists in confining the patient to bed for twenty- 
four hours as a precaution and keeping him under observa- 
tion for some days. Iced cloths or a 25 per cent, solution 



158 DISEASES OF THE NOSE, THROAT, AND EAR 

of aluminum acetate on cloths may be applied if edema or 
inflammation seem to require it. 

Paraflin injections not only push the cellular tissue aside, 
but infiltrate it to a greater or less extent, so that if too 
much paraffin is injected it is impossible to remove it with- 
out removing the cellular tissue in which it is imbedded. 
After all inflammation has subsided the mass feels somew^hat 
like a little mass of fat beneath the skin, and is somewhat 
readily movable upon the bone beneath. 

Unfavorable results from subcutaneous injections of par- 
affin have been reported as follows : 

Infection followed by slough or abscess. Infection can be 
avoided by careful sterilization and by care to av^oid leaving 
a cylinder of paraffin extending through the skin to the 
mass beneath. 

Pressure necrosis, produced by injecting too much paraffin 
at one sitting or beneath the skin where it is tightly bound 
down by adhesions. 

Deformity from hyperinjection or depositing the paraffin 
in the wrong place. Ordinary skill, prudence, and the 
proper technic will prevent such a disaster from occurring. 

Several cases of embolism have been reported from the 
injection oi fluid vaseHn or paraffin. When the paraffin is 
injected as a solid the danger is less imminent. It will, 
however, be well to have an assistant compress the sides of 
the root of the nose between his thumb and forefinger while 
the injection is being made. 

Congenital Deformities of the Nose. — The most common 
of the congenital deformities of the nose are a bulbous 
condition of the end of the nose and extreme prominence 
of the bridge. The latter is readily removed in the follow- 
ing manner : An incision is made through the skin and 
periosteum down to the bone. The periosteum is then 
stripped from the bone and the parts exposed. It is now 
a comparatively simple matter to remove the redundant 
bone and cartilage by means of a burr driven by a dental 
engine. The skin and periosteum are then placed in their 
former position and the wound brought together by buried 
sutures, which leave no stitch-marks and a linear scar, 
which, in a year or two, becomes practically invisible. 



DISEASES OE 77/ E NOSE 1 59 

When bulbous cnlar<;cnicnt of the tip of the nose is exces- 
sive the redundant skin and fat is best treated by the 
method of Rodman of Philadelphia, who removes a pear- 
shaped piece of skin and subcutaneous structures, being 
careful not to disturb the cartilaginous framework of the 
nose. In cases where the deformity is less pronounced, 
the operation devised by Roe of Rochester serves every 
purpose. 

The end of the nose is turned upward and backward and 
held with a retractor by an assistant ; then sufficient of the 
superfluous tissue is removed or dissected out from the 
inside of the nose to allow the nose to conform to the shape 
that we desire. Great care must, however, be exercised 
not to cut through into the skin, lest we may have after- 
ward a scar or dent in the external surface of the nose. 



DISEASES OF THE ACCESSORY SINUSES OF THE NOSE 

The cavities found in the bones of the skull communi- 
cating with the nasal chambers are the antra of Highmore 
or the maxillary sinuses ; the anterior, middle, and posterior 
ethmoid cells ; the sphenoid cells, and frontal sinuses. The 
relative position of these sinuses in the face is shown in 
Fig. 94. 

The accessory sinuses are phylogenetically ancient struc- 
tures and, like the appendix, are residual organs, although 
their presence in the skull adds lightness without greatly 
diminishing the strength of the bones of the face and nose. 
The antrum of Highmore has its prototype in the amphib- 
ian accessory nasal chamber, which is an organ of smell. 
Like other residual organs, the accessory sinuses vary 
greatly in size and shape in different individuals. They are 
all supplied by the trifacial nerve, and this fact should be 
borne in mind in tracing the route of reflex phenomena. 
Like all residual organs they offer a comparatively feeble 
resistance to the onset of inflammation. 

Differential Diagnosis Between Diseases of the Accessory 
Cavities.-^In disease of the antrum, the frontal sinus, and 
the anterior ethmoid cells the discharge makes its way 
anteriorly and is blown from the nose. In disease of the 



l6o DISEASES OF THE NOSE, THROAT, AND EAR 

middle and posterior ethmoid cells and the sphenoidal si- 
nuses most of the pus finds its way into the pharynx. 

Placing the head well forward between the knees or lying 
upon the unaffected side favors a discharge of pus from the 
maxillary antrum, while the upright position favors a dis- 
charge from the other sinuses. 

Orbital abscess with consequent exophthalmos is most 
frequently the result of disease of the ethmoid bone, but 




Fig 94. — Relation of accessory sinuses, nasal bones and cartilages, canaliculi and nasal 
ducts, and sac to surface. Projection upon surface of outer margins of orbital cavity, of 
conjunctival sac, and of globus oculi upon surface: ^. Antra of Highmore ; /'.frontal 
sinuses (the white cross above the right upper lid shows the relation of the supra-orbital 
nerve to the frontal sinus ; the black cross just beneath the lower lid indicates the relation 
of the infra-orbital nerve to the antrum) ; N, nasal bones ; i, projection of margin of orbit 
upon surface ; 2, projection of eyeball (globus oculi) on surface ; 3, projection of conjunc- 
tival sac upon surface; 4, lacrimal sac ; 5, nasal duct (from the lacrimal sac to the inner 
ends of both eyelids the lacrimal canals can be seen terminating at the eyelids in the puncta 
lacrimalia) ; 6, lateral cartilage of nose (between the cartilage of each side is the carti- 
laginous portion of the septum, upon which they rest); 7, alar cartilages. (Modified 
after Eisendrath.) 



may occur as the result of sphenoid disease. Ptosis, strabis- 
mus, or sudden blindness is generally the result of disease 
of the sphenoid, but narrowing of the field of vision may 
also occur as the result of ethmoiditis or disease of the 
antrum of Highmore. Facial neuralgia is most commonly 
caused by disease of the maxillary antrum. Crust forma- 
tions on the middle turbinate are most common in ethmoidal 
suppuration, but may be present when there is a scanty 



DISKASES OF THE NOSE 



i6i 



discharge from either the maxillary or frontal sinus or from 
the ethmoid cells. 

Inflammation of the antrum of Highmore may be divided 
clinically into four classes: Acute and chronic catarrhal 
inflammation and acute and chronic purulent inflammation. 




Fig. 95. — I, Frontal sinus^ with probe entering it through the adnasal duct ; 2, sphenoid 
antrum, with probe entering it through its ostium ; 3, pharyngeal orifice of the Eustachian 
tube, with catheter in position ; 4, Bowman's probe passed through the nasal duct into the 
nose, a portion of tiie inferior turbinated body has been cut away in order to show the point 
at which the probe enters the nose ; j, m, /, superior, middle, and inferior turbinated bodies; 
O, ostium of the posterior ethmoid cells opening into the superior meatus ; P\ posterior por» 
tion of the Vomer; the rest of the septum has been cutaway. (From a dried preparation.) 



Catarrhal inflammation of the lining mucous membrane of 
the antrum, as is usual in all closed cavities, often degenerates 
into purulent disease, the pus finding its exit through the 
ostium maxillare and escaping into the nose. 

Etiology. — The fangs of the first and second molar teeth 
usually extend into the floor of the antrum, the apex of 
11 



l62 DISEASES OF THE NOSE, THROAT, AND EAR 

the fangs not infrequently reaching a level above that of the 
rest of the floor of the antrum (Fig. 96). Under these 
circumstances it is easy to understand how caries of these 
molar teeth would result in infection of the antrum, and 
undoubtedly caries of the molars involving the pulp-cavities 
of their roots preponderates in the etiology of chronic sup- 
puration. However, a common cause of antrum disease is 
closure of the ostium maxillare as the result of hypertrophic 




^K^^^^S^ 



Fig, 96. — Transverse section of the maxillary sinuses (Zuckerkandl). 



rhinitis and polypoid degeneration of the mucous membrane 
about this opening. Some acute cases can be traced directly 
to the effects of taking cold. The antrum may also be 
infected from disease of the ethmoid cells, the frontal si- 
nuses, the sphenoid sinuses, syphilitic necrosis, etc. 

Pathology. — Soon after the onset of the disease the 
mucous membrane of the antrum becomes greatly swollen 
and edematous and a large amount of seromucus is poured 
out. The inflammation may gradually subside at this stage 



DISEASES OF THE NOSE 1 63 

or the secretion may become purulent. The deeper hiyer 
of the mucous membrane, which in this locahty is the peri- 
osteum, also partakes of the inflammation in chronic cases, 
and exostoses are formed, which, in the form of lamina of 
bone, may project into the antrum in such a manner as to 
nearly divide it into two or more small chambers. The 
mucous membrane of the antrum in some cases becomes 
enormously hypertrophied, pulpy, and covered with granu- 
lations and polypi. 

Symptoms. — At the beginning of the attack there is a 
sense of fulness and pressure beneath the orbit, and pain, 
sometimes agonizing in character, involving the whole side 
of the face. Mastication is generally painful, the teeth of 
the affected side feeling as if elongated and crowded out of 
their sockets. These symptoms are due to a collection of 
fluid within the antrum and closure of the ostium maxillare 
and may last for several days, when the fluid is either evac- 
uated through the ostium maxillare or by an opening through 
the thin median wall ; in rare cases, the alveolus, the cheek, 
or the orbit. After this spontaneous evacuation the pus 
flows for a time, the course of the disease being marked by 
periods of retention, during which there is more or less pain, 
terminating by a discharge of somewhat fetid pus from the 
nostril. Some cases, however, pursue a chronic course 
from the commencement, there being at no time complete 
closure of the ostium maxillare and retention. 

Diagnosis. — A discharge of pus from one nostril, especially 
if periodic in character, which smells and tastes fetid to the 
patient, should always excite the suspicion of disease of the 
antrum. Upon inspection the pus will be found flowing 
from beneath the middle turbinated body. This pus should 
be carefully wiped away with absorbent cotton and the 
patient be directed to lie down upon the unaffected side for 
ten or fifteen minutes, when, if pus reappears beneath the 
middle turbinated body, it is probable that its source is the 
maxillary antrum. If, while the patient is in a dark room, 
a 3-candle-power electric lamp (Fig. 97) is placed within 
his mouth, the face will be lit up by transmitted light, and 
the outhnes of each antrum can be mapped out if both are 
empty. If one is filled with fluid or any other material, that 



.64 DISEASES OE THE jVOSE, THROAT, AND EAR 




side of the face will appear darker. The observer should 
also observe the manner in which the light is transmitted 
into each nasal chamber, and more especially through the 
eyeballs. In some cases the antrum may 
contain fluid, and yet both sides of the face 
and each nasal chamber will be equally 
illuminated by the transmitted light from 
the electric lamp within the mouth ; but if 
the pupil of each eye be observed, that 
of the unaffected side will be the brighter, 
.f-ray photographs often give valuable in- 
formation as to the extent and size of the 
adnasal sinuses and presence or absence 
of disease ; and in cases where it is sus- 
pected that disease not only of the antrum 
but also of other accessory cavities exists, 
this additional means of information should 
not be neglected. 

ProgJiosis. — Spontaneous resolution gen- 
erally occurs in acute catarrhal cases, the 
result of transient closure of the ostium 
maxillare from simply taking cold. Chronic 
suppuration of the antrum rarely if ever 
gets well spontaneously. 

Treatment. — In acute catarrhal cases an 
effort should be made to restore the patency 
of the ostium maxillare in the following 
manner : The parts about the middle tur- 
binated body should be thoroughly co- 
cainized by means of pieces of absorbent 
cotton saturated with a 4 per cent, solution 
of cocain placed within the middle meatus, 
after which an application of a 4 per cent, 
solution of antipyrin and a 3 per cent, solu- 
tion of menthol in olive oil should be made 
with an atomizer, and the parts then cov- 
ered with powdered calomel. These ap- 
plications should be made daily at the physician's office, 
the patient in the meanwhile using at home every hour or 
two a spray of adrenalin of the strength of i : 10,000. 



Fig. 97. — Ferguson's 
antrum illuminator. 



DISEASES OE THE NOSE 1 65 

Treated in this manner, resolution <^enerally occurs in three 
or four days. 

It should be borne in mind that all of the accessory si- 
nuses of the nose can be inflated with air in the same man- 
ner as the ear by means of Politrjcrs air-bag. The parts in 
the neighborhood of the ostium maxillare should be cocain- 
ized in order to render this orifice as patulous as possible. 
The patient should then lie down with the affected antrum 
uppermost, and puff out his cheeks and close the auditory 
meati with the forefinger-tips, in order to protect as far as 
possible the middle ear from overinflation. The Politzer 
air-bag is now filled with the vapor of iodin-chloroform 
(Formula 92), its nozzle inserted into the nostril, both alae 
being closed about it with the thumb and fingers of the left 
hand in such a manner as to produce an air-tight joint. The 
bag IS then suddenly compressed with the right hand and 
chloroform vapor enters all the accessory cavities of the 
nose as well as the middle ear. With the patient in the 
position described above air bubbles through an accumula- 
tion of mucus or mucopus in the antrum and forces it out 
through the ostium maxillare into the nose, and the pro- 
cedure may be repeated sufficiently often to completely empty 
this cavity, the chloroform vapor acting as an anesthetic 
antiseptic, and the heat of the parts causes it to expand to 
a greater bulk than an equal volume of air would do. 

This method of treatment is especially useful in the early 
stages of disease of any of the nasal accessory cavities. The 
intense frontal headache sometimes resulting from vacuum 
congestion of the frontal sinuses in acute nasal catarrh 
can be relieved quickly by applying pledgets of absorbent 
cotton saturated w^ith a 4 per cent, solution of cocain to the 
neighborhood of the infundibuli and, after their removal, 
inflating with chloroform-menthol or chloroform-iodin vapor 
the frontal sinuses in the manner described above. 

The Politzer air-bag is filled with chloroform-menthol 
vapor by the following method : A glass-stoppered bottle 
is kept partly full of chloroform in which some crystals of 
menthol are dissolved. The portion of the bottle above the 
lev^el of the fluid soon becomes filled w^ith the vapor of chlo- 
roform-menthol, and it is only necessary to insert the nose- 



1 66 DISEASES OE THE NOSE, THROAT, AND EAR 



piece of the Politzer bag in the mouth of the bottle and 
allow the bag to expand to fill it with menthol-chloroform 
vapor. 

The accessory sinuses can also be inflated by Valsalva's 
mctJiod, that is, closing the nose and blowing violently into 
it. They may be aspirated by inserting the nozzle of a 

Pohtzer bag into the patient's 
nose and allowing the empty 
bag to expand while the 
patient is blowing out his 
cheeks. Closing one nostril 
and sniffing the inspired air 
violently through the open 
nostril has a tendency to 
aspirate the accessory si- 
nuses. In some cases the 
rarefaction of the air by 
this method in an inflamed 
antrum is sufficient to cause 
pain, and in certain cases is 
sufficient to enable a patient 
to aspirate fluid from his 
antrum when in the hori- 
zontal position with the af- 
fected antrum uppermost. 

Acute cases of antrum 
disease should be treated 
by the surgeon once a day 
in the manner described 
above. The patient, in the 
meanwhile, should spray his 
nose every two hours with 
a I : 5000 solution of adrenalin. Treated in this manner 
there is frequently little or no pain after the first inflation. 

In chronic cases efficient drainage is of primary impor- 
tance. This may be accomplished by drawing the second 
molar tooth and penetrating the antrum through the socket 
of its inner fang by means of a small trocar and cannula. 
In the majority of instances this is readily accomplished, 
but Fig. 98 shows a section of a skull where it is difficult 




Fig. 98. — Illustrating the difficulty of open- 
ing the antrum through the root-cavities 
when the antrum is small or abnormal in 
location (Jour, of Laryn., Oct., 1895). 



DISEASES OE THE NOSE 



167 



to reach the antrum by this route. In such cases the trocar 
may be made to pierce the cavity of the antrum tlirou^^h 
the canine fossa or, preferably, throu< 



A\ the inner wall of the 




Fig. 99. — Section through the nose, showing needle {B) entering the orbital cavity 
through the middle meatus when the lateral wall slopes outword ; A shows needle entering 
the antrum through the inferior meatus. Outline : Zuckerkandl, Anatomic der Nasenhohle. 
(Coffin.) 

nose beneath the inferior turbinated body by means of Halle's 
trocar and cannula (Fig. 100). The parts are first cocain- 
ized in the usual manner and the trocar and cannula thrust 





Fig. 100. — Halle's trocar and cannula for piercing the antrum through the inferior 
meatus: a, Trocar and cannula ; b, probe or obturator, by means of which the cannula can 
be introduced daily into the antrum through the opening made by the trocar. 



through the thin bone beneath the inferior turbinate in an 
inward, outward, and upward direction. The trocar is then 
withdrawn and the antrum washed out through the cannula. 



1 68 DISEASES OF THE NOSE, THROAT-, AND EAR 

The opening thus made remains for some time patulous and 
there usually is no difficulty in reinserting the cannula and 
blunt obturator (Fig. lOO, b) as required from day to day. 
When an attempt is made to open the antrum through the 
nose the proximity of the orbit should be remembered. 
The antrum varies in size from a capacity of less than 2 
fluiddrams to as many fluidounces. Small antra may be the 
result of lack of development of the entire side of the face 
or encroachment of the nasal wall or great concavity of the 
floor of the orbit. Douglas observed a case in which the 
antrum was greatly narrowed by a curious guttering of the 
floor of the orbit into the antrum. 

No matter in which position the opening of the antrum 
is made, the cavity should be thoroughly cleansed once a 
day by means of a suitable syringe. The antrum should 
first be irrigated with warm borated water in order to re- 
move the major portion of the accumulated mucus. Equal 
parts of Dobell's solution and peroxid of hydrogen should 
then be thrown into the antrum and allowed to bubble out 
through the nose for a moment or two. The antrum is 
then again irrigated with warm borated water. A quantity 
of I per cent, or even 2 per cent, nitrate of silver solution 
sufficient to completely fill the antrum is then thrown in 
and allowed to remain for half a minute or longer, and is 
then washed out with the boric acid solution and the antrum 
dried by means of a current of warm air. This thorough 
treatment should be done by the surgeon each day. When 
the opening is made through the alveolus, its patency can 
be maintained by means of a plug of aluminum worn by the 
patient. 

When the opening is made through the alveolus it is 
possible for the patient to wash out his antrum by 
means of a fountain syringe provided with a suitable 
nozzle. When it is impossible to visit the surgeon's 
office at frequent intervals, this should be done once or 
twice a day by means of a quart or more of saturated 
boric acid solution used as hot as can be tolerated. Cures 
of this disease are sometimes brought about by this method. 

In the treatment of diseases of the maxillary antrum it 
seems needless to remark that any coexisting disease of the 



DISEASES OF 77/E NOSE 169 

nasal chambers should receive the careful attention of the 
surgeon. 

In a certain percentage of cases these milder measures 
are insufficient to bring about a cure. For cases of this 
kind operations have been devised known as Kustcrs, 
the Caldzvcll-Liic, and Jansciis. Jansen claims that when 
one sinus is involved all the sinuses of that side of the face 
are probably more or less affected, and hence opens all of 
the sinuses at one operation. 

After the patient has been etherized the jaws are separated 
by a mouth-gag inserted on the side opposite to that to be 
operated on. To prevent blood reaching the pharynx from 
the mouth a strip of gauze may be packed between the 
jaws and the cheek as far back as possible beyond the 
wound, and removed from time to time when it becomes 
saturated with clots. The tongue is controlled by means 
of suitable forceps or a suture inserted through its tip, so 
that it may be drawn forv/ard when necessary to sponge 
blood from the pharynx should any reach that locality from 
the posterior nares. The patient should lie on the side to 
be operated on with the head in such a position as to 
facilitate the gravitation of blood from the nose and mouth, 
but if blood reaches the pharynx it can be removed by 
gauze sponges held in long hemostats. 

The cheek is retracted by means of a blunt retractor and 
an incision made at the junction of the cheek with the jaw 
from the posterior border of the alveolus to the anterior 
border of the canine fossa. The anterior and lateral bony 
surface of the antrum is then uncovered by means of a 
periosteum elevator, and the bone removed by means of a 
chisel and rongeur forceps as far forward as the nasal wall 
and as far backward as the anterior border of the masseter 
muscle, and vertically from the floor of the antrum to near 
the infra-orbital canal If the lining membrane is not 
wounded the operation up to this point will probably be 
nearly bloodless. 

The mucous membrane is now incised and the cavity of 
the antrum examined by means of the finger and, after 
hemorrhage has ceased, inspected. The mucous membrane 
will probably be found immensely thickened, granular, and 



I/O DISEASES OE THE NOSE, THROAT, AND EAR 

covered with pus. One or more mucous polypi may be 
present and exposed bone detected with the finger-tip. 
The diseased mucous membrane is now thoroughly removed 
with a sharp curet, and, if possible, with the same instrument, 
a large portion of the bony nasal wall of the antrum, the little 
finger being inserted in the nose to facilitate the procedure. 

In cases where the ethmoid cells and sphenoid antrum 
are normal, the operation should be concluded without the 
further destruction of tissue. However, where the ethmoid 
cells are known to be diseased, they may be thoroughly 
opened or cureted away as far back as the sphenoid antrum, 
the anterior wall of which may also be removed with the 
curet if necessary. 

The remains of the nasal mucous membrane of the nasal 
wall of the antrum are now turned into the antrum to 
replace as far as possible its own mucous membrane 




Fig. ioi. — Frontal sinus illuminator. 

previously removed by the curet, and the cavity is loosely 
packed with iodoform gauze. The oral wound should not 
be stitched. In the course of time it contracts to a small 
opening or becomes permanently closed. 

The gauze packing is removed in whole or in part on 
the second or third day, and may or may not be replaced 
as seems better in the judgment of the surgeon. After the 
gauze has been permanently removed the antrum should 
be cleansed daily with sterile water or Dobell's solution 
until the heaHng process is complete. This occurs in the 
course of five or six weeks, the antrum being greatly 
reduced in size during the process. 

Occasionally the frontal sinus drains directly into the 
antrum, and under such circumstances, if the frontal sinus 
were the seat of purulent inflammation, it would be impossi- 
ble to bring about a cure of the antrum disease as long as 
the purulent inflammation of the sinus existed. 



DISEASES OE THE NOSE 



171 



Inflammation of the Frontal Sinus. — Acute catarrh of the 
frontal sinus probably is more common than similar disease 
of any of the other accessory sinuses. The disease, how- 
ever, more rarely goes on to suppuration because the infun- 
dibulum often affords ample drainage from the most de- 
pendent portion of the cavity. Suppuration in the frontal 
sinus probably only occurs as the result of comparatively 




Fig. 102. — Acute catarrh of the frontal sinus. (Photograph by Pfahler.) 



long closure of the infundibulum, traumatism, gonorrheal 
infection, maggots in the nose, syphilis, and the develop- 
ment of tumors within the sinus. 

The symptoDis are frontal headache, which sometimes 
develops into severe pain, with nausea and vomiting. When 
the transilluminator (Fig. lOi) is placed beneath the brow, 
the light is transmitted better by a large normal sinus than 
by one containing pus or a tumor. However, the size and 



1/2 DISEASES OE THE NOSE, THE OAT, AND EAR 

shape of the frontal sinus varies so greatly in different 
individuals that a much more satisfactory result can be 
obtained by an ;r-ray photograph than by transillumination. 
It is usually possible, by means of a good photograph, to 
not only determine whether the sinus contains pus or a 
tumor but also secure valuable information as to its size, 
the presence or absence of septa, the condition and size of 
the ethmoid cells, the antra of Highmore, etc. 




Fig. 105. — Case shown in Fig. 102 after recovery. Treatment consisted of removal of 
a small polypus from beneath the middle turbinated body and daily inflation of sinus with 
chloroform-iodin vapor, which was invariably successful in controlling pain for several 
hours. (Photograph by Pfahler.) 



Treatment. — The headache and pain can sometimes be 
relieved in the following manner : The parts about the 
infundibulum are first thoroughly cocainized. The nozzle 
of a Politzer bag filled with the vapor of chloroform or 



DISEASES OE THE NOSE 



•73 



menthol is then so placed within tlie nose that its orifice 
points toward the infundibulum and the patient is told to 
" puff out " his cheeks. If now the rubber bag is suddenly 
compressed, some of the vapor may penetrate the frontal 
sinus and be followed by instant relief from frontal head- 
ache and pain. Should this maneuver succeed, Politzcr's 
bag should be used in the manner described at sufficiently 




^^i^V" 




'm 



Fig. 104. — a, Posterior ethmoid cells ; i, anterior ethmoid cells having no communica- 
tion with the posterior cells ; c, sphenoid sinus and its communication with the posterior 
ethmoid cells ; rt', frontal sinus ; e, infundibulum communicating with the middle meatus ; 
/, maxillary sinus ; ^, nasal canal communicating with the lacrimal sac. (Hirschfeld.) 



frequent intervals to prevent a return of the frontal head- 
ache. The patient should spray his nose every two hours 
with a I : 10,000 solution of adrenalin as a home treatment, 
and every effort should be made to maintain the infundibu- 
lum in a patulous condition until the inflammation of the 
frontal sinus subsides. To prevent recurrent attacks of 
catarrhal inflammation of the sinus it may be desirable to 
remove the anterior portion of the middle turbinated body. 



174 I^ISEASES OF THE NOSE, THROAT, AND EAR 

The distance from the floor of the frontal sinus through 
the nasal frontal duct is rarely more than f inch. The 
distance from the nasal end of the duct to the lower border 
of the bulba ethmoidalis, the lowest possible region of 




Fig. io6. 

Figs. 105, 106. — Removal of anterior end of middle turbinated body with forceps and 
snare (Grunwald). 

obstruction to frontal drainage, is about f inch (Fig. 104). 
When using adrenalin the patient should be told to direct 
the spray from an atomizer so that it will reach the middle 
turbinate region. Not infrequently a small polypus is 



DISEASES OF THE NOSE 1 75 

found beneath the middle turbinate anteriorly, and its re- 
moval is followed by a cessation of recurrent attacks of 
frontal sinus inflammation. However, the obstruction 
generally is due to hyperemia and swelling of either the 
lateral wall of the middle turbinated body or the mucous 
membrane of the hiatus semilunaris, the uncinate process, 
and the bulba ethmoidalis. Suitably treated, at least 95 
per cent, of acute cases recover without operation, but where 
relapses are frequent it is advisable to remove the anterior 
third of the middle turbinate with Gri^inwald's forceps and 
snare (Figs. 105, 106) to facilitate treatment. 

Clironic Purulent Disease of the Frontal Sinus. — Symptoms. 
— The headache is usually persistent, but may assume an 
intermittent type. There may be deep-seated pain on 
pressure on the bone over the frontal sinus. Upon inspec- 
tion the parts about the infundibulum will be found red 
and swollen and covered by a small amount of pus, some- 
times offensive in character. If the discharge is greatly 
obstructed, the roof of the orbit may be so far crowded 
downward as to produce displacement of the eyeball with 
diplopia or even amaurosis, while the anterior wall of the 
cavity may bulge forward in such a manner as to produce 
marked facial deformity. Should the posterior wall be dis- 
placed, dulness, apathy, increased headache, and other 
symptoms referable to the brain will probably manifest 
themselves. Meningitis or brain-abscess may occur. 

Treatment. — Chronic cases require irrigation with a mild 
alkaline solution. This may be accomplished by means of 
Hartmann's cannula (Fig. 107) screw^ed on to syringe <:, 
Fig. 38. This cannula should be made of virgin silver, so 
that its curve can be slightly changed to suit varying con- 
ditions. The parts are first cocainized with a pledget of 
cotton saturated with a 4 per cent, solution of cocain and 
then sprayed w^ith a i : 1000 solution of adrenalin, and an 
effort made to probe the sinus with a small virgin silver 
probe. Should the probe enter the sinus, it is withdrawn ; 
the shape of the Hartmann cannula is bent to correspond 
with that of the probe and, after being screwed on to the 
syringe, is inserted in the sinus. The solution used for 
syringing should be of a temperature of about 120° F., 



176 DISEASES OF THE NOSE, THROAT, AND EAR 

and great gentleness should be employed in syringing to 
avoid giving pain. 

If the cannula fits somewhat loosely into the adnasal 
duct, so that fluid syringed into the frontal sinus readily 
escapes around the cannula, it will be safe to add a propor- 
tion of peroxid of hydrogen to the fluid used for syringing. 
However, if there is any obstruction to the return flow of 
fluid syringed into the sinus the use of this substance 
should be avoided. After the sinus has been thoroughly 
cleansed, any retained fluid should be removed by blowing 
air through the cannula with the syringe-bulb. After the 
sinus has been cleansed and dried, J dram of a 10 per cent, 
solution of argyrol should be injected through the cannula 





Fig. 107. — Hartmann's frontal sinus cannula. The instrument should be so con- 
structed as to screw on to a, h, or c. Fig. 38, and the tube made of pure soft silver, so that 
its curve can readily be slightly changed. 

by means of syringe a^ Fig. 38, and allowed to remain. 
The action of this solution is that of a sedative, slightly 
astringent antiseptic. It spreads itself over the walls of 
of the sinus and is either absorbed or slowly dribbles out 
through the adnasal duct into the nose. 

Instead of employing Hartmann's cannula, the cannula 
5 or 6, Fig. 2)'^, if suitably curved, may be used. The 
conic shape of this cannula is an advantage in some cases, 
and when employed with the conic nozzle 7, Fig. 38, does 
away with the necessity of unscrewing the syringe from the 
cannula each time it is refilled with fluid. 

Most cases of chronic suppuration of the frontal sinus are 
greatly improved by syringing and the appHcation of argy- 
rol. There remains, however, a certain proportion of cases 



DISEASES OE THE NOSE \JJ 

where, as the rcsuh of hyperplasia of the mucous membrane, 
the presence of polypi or necrosed bone, these measures are 
not adequate, and under such circumstances, in order to 
effect a cure of the chronic suppuration, it is necessary to 
make a sufficiently lari^e opening through the external plate 
of the frontal bone to thoroughly expose the sinus. In 
most of such cases in order to effect a cure it will be 
necessary to curet away every vestige of mucous membrane, 
pack the sinus with gauze, and allow it to fill up with granu- 
lations until practically obliterated. 

Bryan, Hajck, Killian, Agston, Luc, and Kuhnt have 
devised operations for exposing the frontal sinus by remov- 
ing a portion of its external wall. 

In chiseling into the frontal sinus it should be borne in 
mind that the suture at the root of the nose between the 
nasal bone, nasal process of superior maxillary, and the 
frontal bone is on a level with the floor of the sinus. This 
suture is T shaped and usually easily demonstrated when 
the bone has been denuded of periosteum. The chiseling 
should be done immediately above the center of this suture 
beneath the superciliary ridge until the antrum has been 
encountered, after which the bony opening should be en- 
larged sufficiently with rongeur forceps ; but in order to pre- 
vent deformity the supercihary ridge should be encroached 
upon as little as possible. However, Kuster, Lathrop, 
and others have devised osteoplastic operations in which a 
flap of periosteum and bone is replaced after the sinus has 
been cureted. 

The nasofrontal duct should be located with a probe and 
enlarged only at the expense of the anterior and median 
wall in order to avoid opening the cranial cavity. Some 
operators advocate passing one end of a strip of gauze from 
the antrum, after it has been cureted, through the naso- 
frontal duct into the nose. The strip of gauze is seesawed 
back and forth until it has removed all the mucous mem- 
brane of this passage. The end of the strip protruding 
from the nose is then cut off close up to the naris and the 
other end of the gauze packed into the antrum as a first 
dressing. The gauze is removed daily and the antrum syr- 
inged with a I : 2000 solution of sublimate and repacked 
12 



178 DISEASES OF THE NOSE, THROAT, AND EAR 

until it has filled with granulations. At the end of one or 
two weeks this process generally has sufficiently advanced 
to permit closing the skin wound; after which, if necessary, 
the parts may be irrigated through the nose by means of 
Hartmann's cannula. Because the sinus is obliterated com- 
pletely by the granulations that finally completely fill it, 
the amount of depression over the former location of the 
antrum and the consequent deformity is less than would be 
expected. 

Killian's operation consists, after first shaving off the hair 
of the eyebrow and sterilizing the field of operation, in 
making an incision through the skin and periosteum from 
the temporal end of the eyebrow to the middle of the base 
of the nose. The sinus is then exposed with a chisel, care 
being taken not to wound its lining mucous membrane in 
order to prevent hemorrhage. The vertical elevation of the 
sinus is discovered by reference to a skiagraph taken pre- 
vious to the operation and by inserting a probe between 
the mucous membrane and bone. A vertical incision 
through the skin and periosteum is now made from the 
highest point to which the sinus extends down to the nasal 
end of the original wound, thus producing a triangular 
flap of skin and periosteum which is dissected upward from 
the bone. 

A sufficient amount of the outer table of the frontal bone 
is now removed with chisel and rongeur forceps to permit 
of the entire mucous membrane lining the sinus being 
cureted away. The ethmoid cells and even the sphenoid 
antrum may, if necessary, be opened. The bony floor of the 
antrum at its nasal portion is next chiseled away and the 
nasal mucous membrane incised longitudinally and stretched 
into the wound. The flap of skin and periosteum is replaced 
and stitched into position. The patient is instructed not to 
blow his nose, but to suck all secretions into his pharynx. 

Mucocele of the frontal sinus is a retention cyst containing 
a serous exudate from the mucous membrane. The con- 
tents of the cyst are prevented from escaping by partial or 
complete occlusion of the nasofrontal duct. 

Syinptoms. — Pain, neuralgic in character, due to pressure 
caused by the accumulation. The pressure may be so 



DISEASES OE THE NOSE 1 79 

great as to cause tlie tumor to bulge into the nose. The 
bone over the frontal sinus, especially the orbital portion, 
is painful on pressure. 

Treatment. — If the cystocele bulges into the nose, it 
should be incised and its contents allowed to escape. When 
there is no bulging into the nose and an x-ray photograph 
discloses the probable presence of a fluid within the frontal 
sinus, the sinus should be opened and the contents of the 
cyst evacuated and free drainage established into the nose 
before the external opening is allowed to close. 

Inflammation of the Ethmoid Cells. — The most common 
diseases affecting the ethmoidal sinuses are acute and 
chronic catarrhal inflammation and purulent disease. Puru- 
lent disease of the ethmoid cells is usually associated with 
caries or necrosis of the bony structures, and is some- 
times followed by exophthalmos, orbital abscess, and even 
meningitis and death. The name necrosing et/unoiditis 
was employed Ijy Woakes of London to designate an in- 
flammation usually resulting in caries or necrosis of the 
inferior turbinated process and other parts of the ethmoid 
bone ; characterized, after caries has occurred, by the 
presence of a tenacious, creamy white, mucopurulent 
discharge from a sinus or cleft in the middle turbinated 
body, and usually by the presence of exuberant granulations 
and polypi, the result of the irritation of necrosed spicules 
of bone upon the surrounding soft tissues. While the 
conclusions of Woakes have not received general acceptance 
by laryngologists, yet the following diagrams (Figs. 108, 
109) represent very well indeed conditions not infrequently 
resulting from ethmoid disease. 

Pathology. — The mucous membrane of this portion of 
the nose extends inward to line the cells and trabeculae of 
the middle turbinated body, and is inseparable as a mem- 
brane from the periosteum beneath. Inflammation of this 
mucoperiosteum results in necrosis. The inflamed mucous 
membrane and cellular tissue, proliferating after its kind, 
forms large masses of granulation tissue and polypi. 
These polypi partake more or less o{ a fibrous charac- 
ter in proportion to the amount of connective tissue 
involved in the proliferating process. The process of ex- 



l8o DISEASES OF THE A^OSE, THROAT, AND EAR 

foliation is not always characterized by the presence of 
exuberant granulations or mucous polypi, but there is 
always a discharge of tenacious, creamy mucopus, which 
adheres to the orifice of the sinus or cleft from which it 
exudes. Sometimes after the exfoHation of the necrosed 
bone the disease undergoes a spontaneous cure, a crater or 
cleft in the middle turbinated body indicating the spot from 
which the dead bone has exfoliated (Fig. iii). 

When the deeper cells of the ethmoid are involved the 
pus, instead of finding its way into the nose, sometimes 
breaks through into the orbit with resulting orbital abscess. 





Fig. io8 



■Diagram showing an early stage of 
ethmoiditis (Woakes) . 



Fig. 109. — More advanced stage of 
the same disease, showing '' cleav- 
age " of the middle turbinated bodies 
(Woakes). 



In some cases of orbital abscess pressure on the eyeball 
results in a flow of pus into the nose. 

Symptoms. — An early stage of the disease is well repre- 
sented in Fig. 108. A red and sw^oUen middle turbinated 
body may press upon the septum. Should both turbinated 
bones be diseased, the septum is nipped between the 
hypertrophied bodies, and reflex skin rashes upon the face, 
such as erythema or acne, or eye disease, or any of the reflex 
nasal symptoms previously mentioned, may be present. 

In Fig. 1 10 " cleavage," with exfoliation of necrosed bone, 
is taking place, while from the clefts polypi or proliferating 
granulation tissue protrudes. Fig. 109 shows *' cleavage " 



DISEASES OE 77/ E NOSE 



81 



without proliferation of the soft tissues, the commonest form 
of the affection. From the cleft or from a sinus in the bone 
exudes a creamy, tenacious mucus, which the patient re- 
moves from his nose with great difficulty. At this stage 
of the disease nasal asthma and cough or paresis of the 
soft palate are reflex symptoms often present. 

Treatment. — Drainage from the ethmoid cells can be 
greatly improved by the removal of a portion of the middle 
turbinated body, either by means of the snare or, when 
there is sufficient space, nasal scissors or Myles' or Griin- 
wald's forceps. In cases where the ethmoid cells lie very 





Fig. iio. — Granulation tissue protruding 
from the clefts in the middle turbinated 
bones (Woakes). 



Fig. III. — Crater-like cleft in the turbin- 
ated bone, resulting from necrosing ethmoid- 
itis (Woakes). 



superficial this operation, which is easily accomplished, 
gives notable relief. When an orbital abscess has formed 
it should be opened and, if deemed necessary, the curet 
used until a sufficiently wide opening is established into the 
nose. The parts are then packed with gauze, which is 
renewed from day to day, care being used at each dressing 
to maintain the opening into the nose until the parts have 
thoroughly healed, the curet being used from time to time 
if necessary. 

Myles' nasal cutting forceps (Fig. 112) is a very useful 
instrument for removing quickly granulation tissue and 
small portions of diseased bone. With this admirable 
instrument the diseased portion of the middle turbinal can 



1 82 DISEASES OF THE NOSE, THROAT, AND EAR 

generally be cut away quickly and easily and leaves a clean 
smooth wound. However, occasionally portions of sclerosed 
bone are encountered too hard to be cut away with the 
Myles forceps, and under such circumstances Griinwald's 




Fig. 112.— Myles' alligator nasal cutting forceps. 

forceps (Fig. 1 13) will accomplish the desired result, although 
much more slo\Yly. Both instruments are necessarily some- 
what bulky, and occasionally there is not room between the 
septum and the turbinated bone to admit of their being 




Fig. 113. — Griinwald's cutting forceps, for operation on the middle turbinal. 

used. Under such circumstances a nasal curet, the trephine 
(Fig. 62), or a burr provided with a suitable shield should 
be employed to remove all tissue that interferes with the 
proper drainage of the parts. 



DISEASES OE TJIE NOSE 183 

Pro(]^iiosis. — The course of tlie disease, even under proper 
treatment and operative procedures, is generally tedious, 
but a cure is sooner or later brought about by persistent 
effort, while in some instances it may be quickly and easily 
obtained 

Empyema of the Sphenoidal Cells. — It is probable " that 
catarrhal disease of the sphenoidal cells is of not infrequent 
occurrence. Generally it subsides spontaneously. How- 
ever, the situation of the ostium sphenoidium is such as to 
favor the development of purulent disease of the sphenoid 
with final necrosis, and there are numerous cases in which 
this has occurred. 

Symptoms. — Purulent discharge through the nose and 
pharynx ; pain, at first in the upper part of the throat, and 
later involving the whole side of the face. Ocular symp- 
toms occur as the result of the proximity of the optic 
foramina, and vary from impairment of the periphery of the 
field of vision to complete blindness. 

The treatment should consist in the use of disinfectant 
sprays and washes (Formulas i to 10) and the application 
of alterative solutions to the mucous membrane of the 
upper part of the nose and vault of the pharynx. This 
will suffice for the milder cases of acute catarrhal inflam- 
mation. 

A silver probe, slightly curved at the tip, passed between 
the septum and middle turbinated body just above its in- 
ferior border can be moved about in such a manner as often 
to enter the opening into the sphenoid antrum (Fig. 95). 
When the opening into the antrum has been thus located, 
a long silver tube (Fig. 38, 4), fitted to syringe <r, can be 
made to follow the tract of the probe and the antrum 
cleansed and medicated. For washing out the antrum 
either normal salt solution or a saturated boric acid solution 
may be employed. 

Treatment is greatly facilitated by the removal of as 
large a portion of the middle turbinate as possible. When 
this has been done, the ostium may be enlarged by means 
of a euret sufficiently to permit the use of Griinwald's 
forceps, with which as large a portion of the anterior wall 
of the sinus as is necessary may be clipped away. 



THE PHARYNX 

ANATOMY OF THE PHARYNX 

The pharynx is a conic, musculomembranous bag sus- 
pended base up from the basilar process of the occipital 
bone. It extends downward to the lower border of the 
cricoid cartilage and fifth cervical vertebra, where it merges 
into the esophagus. It is composed of three layers — an 
inner, mucous ; a middle, fibrous, sometimes called the 
pharyngeal aponeurosis ; and an outer, muscular layer. 

Relations of the Pharynx. — Posteriorly the pharynx is 
connected by loose cellular tissue with the first five cervical 
vertebrae (Fig. 95). The second, or atlas, forming a prom- 
ontory extending forward into the pharynx on a level with 
the palate. On each side posteriorly are the longus colli 
and recti capiti antici muscles (Fig. 114). Laterally are the 
styloid processes with their muscles, the internal carotid 
arteries, the internal jugular vein, the eighth, ninth, and 
sympathetic nerves. Near its apex are the lobes of the 
thyroid gland, the common carotid and lingual arteries, the 
lingual nerves, and the sternohyoid muscle. 

Divisions. — The pharynx is divided into the nasopharynx, 
sometimes called the posterior nasal space, the oropharynx, 
and laryngopharynx. The nasopharynx extends down- 
ward to the edge of the soft palate, the oropharynx from 
this to a line drawn through the cornua of the hyoid bone, 
and the laryngopharynx the rest of the distance to the com- 
mencement of the esophagus at the fifth cervical vertebra. 

Attachments. — The pharynx is attached to the internal 
pterygoid plate, pterygomaxillary ligament, inferior maxil- 
lary bone, base of the tongue, cornua of hyoid bone, stylo- 
hyoid ligament, and the thyroid and cricoid cartilages. 

Muscles. — There are seven muscles — the superior, middle, 
and inferior constrictors, two stylopharyngei, and two palato- 

184 



ANATOMY OF THE ITIARYNX 



185 




Fig. 114. — Posterior view of pharynx and larynx, as shown in a coronal section of the 
skull made through the level of the mastoid processes: a. Posterior crico-arytenoid mucle; 
/'. lingual tonsil; c palatopharyngeus; li , stylopharyngeus ; e, cartilaginous portion of Eu- 
stachian tube and levator palati ; f, facial nerve ; a'', cavernous sinus ; //. internal carotid ; 



/.sixth nerve; /.third nerve; /%, fourth nerve; /.antrum of mastoid; 



mastoid cells ; 



;/. middle turbinated; £?, inferior turbinated; /, azygos uvula;; (7. tonsil ; r, aryteno-epi- 
glottidean fold; ,v, aditus laryngis ; /, tubercle of Santorini; /c, beginning of esophagus, 
(Eisendrath.) 



1 86 DISEASES OF THE NOSE, THROAT, AND EAR 

pharyngei muscles. The latter, covered by mucous mem- 
brane, form the anterior pillars of the fauces, the stylo- 
pharyngei, the posterior pillars. A not very uncommon 
anatomic peculiarity is that one or both the palatopharyn- 
gei are completely surrounded by mucous membrane, so 
that a probe can be passed between them and the rest of 
the outer wall of the pharynx. 

Arteries. — There are four arteries supplying the pharynx 
— two branches of the external carotid and two branches 
of the internal maxillary. These are the ascending pharyn- 
geal and branches from the superior thyroid ; descending 
pharyngeal and pterygopalatine. Occasionally arteries as 
large as the radial are seen pulsating on either side beneath 
the mucous membrane of the pharynx. These are supposed 
to be displaced occipital arteries. 

Nerves. — The pharynx is supplied by a plexus composed 
of branches from the pneumogastric, glossopharyngeal, 
superior laryngeal, and the superior cervical ganglion of 
the sympathetic. 

The mucous membrane of the nasophar>aix is covered 
with stratified, ciliated, columnar epithelium, the oropharynx 
with squamous epithelium, and the laryngopharynx with 
squamous and ciliated epithelium anteriorly. There are 
simple follicular glands, compound follicular, and racemose 
glands. 

Tonsils and Lymphatics of the Pharynx.— The laryngo- 
pharynx has few or no lymphatics. Above the supply is 
profuse, being located mainly in the mucous membrane of 
the superior and posterior wall. 

The tonsils are a part of an irregular ring of adenoid 
tissue surrounding the pharynx and continuous with the 
general lymphatic system. There are seven tonsils : the 
faucial, the tubal, the pharyngeal, and the lingual. The 
faucial tonsils are situated one on each side of the fauces 
between the anterior and posterior pillars of the fauces. 
The Hngual tonsils are situated at the base of the tongue, 
the tubal tonsils at the pharyngeal Eustachian orifices, and 
the pharyngeal tonsil in the vault of the pharynx posterior 
to the nasal orifices. Any of these tonsils when hyper- 
trophied may cause annoying symptoms, especially in child- 



ANATOMY OF TIIK PHARYNX \%J 

hood; the third or pharyngeal tonsil, the so-called adenoid 
vegetations. 

Above the tonsils and between the anterior and posterior 
pillars is situated the triangular /<'^5.y^ sitpratoisiUaris. Here 
a number of crypts extend vertically into the tonsil, the 
retention of whose excretions is supposed to play an im- 
portant role in the production of peritonsillar abscess. The 
number of crypts, both vertical and horizontal, rarely 
exceeds fifteen for each tonsil. They vary in length from 
\ to I inch or possibly even more in tonsillar hypertrophy 
(Fig. 122). The tonsils are frequently adherent to the 
anterior pillars in such a manner as to form pouches, which 
are most effective culture-tubes for the propagation of patho- 
genic organisms. 

The fuyictioiis of the tonsils are similar to those of other 
lymphatic glands. As a part of the hemopoietic system 
they form young leukocytes, most of which pass into the 
circulation, but some escape into the free mucous surface, 
where they may exercise a phagocytic action. They also 
excite old leukocytes, which probably carry off with them 
effete products. According to G. B. Wood, the faucial 
tonsils drain into the deep lymphatics and not the superficial 
lymphatics of the neck. The '* tonsillar gland," Wood states, 
is placed external and slightly anterior to the internal jugu- 
lar vein. Hypertrophy of this gland means its dislocation 
outward and forward, but generally it can be pushed back 
under the sternocleidomastoid muscle, which is not the case 
with hypertrophied superficial glands. In a child one week 
old this gland was but little larger than its fellows, while in 
children who were six or more months of age the " tonsillar 
gland " was twice to four times larger. *' Does it not seem 
possible," Wood states, " that this enlargement consequent 
to birth may be due to the absorption of toxins through the 
faucial tonsils ?" 

The tonsils are most active during youth, while the thy- 
mus, a large blood-forming gland, is atrophying. There is 
considerable difference of opinion as to the phagocytic action 
of the tonsils, some authorities claiming that they are not 
even able to protect themselves, and that the tonsils con- 
stitute a weak part of the throat and expose the system to 



1 88 DISEASES OF THE NOSE, THROAT, AND EAR 

the inroads of diphtheria, tuberculosis, syphiHs, and other 
diseases. 

In evidence of the difference in the behavior of tonsillar 
epithelium toward dust and bacteriae, Jonathan Wright 
dusted carmin over the tonsil. Fifteen minutes later all the 
particles of carmin had passed through the epithehum. into 
deeper layers and could be detected in sections under the 
miscroscope ; while bacteria, situated at the exact point 
where the carmin entered, remained quiescent and unab- 
s orbed. 

Mechanically the Hngual tonsil is most apt to prove trou- 
blesome as the result of hypertrophy after middle life if at 
all, while hypertrophy of the faucial and pharyngeal tonsils 
are distinctly diseases of childhood. 

DISEASES OF THE NASOPHARYNX OR POST- 
NASAL SPACE 

Postnasal catarrh may be either secondary, as when a 
nasal catarrh discharges into the postnasal space, or the 
disease may be primary and extend to either the nose or 
Eustachian tubes. The nasopharynx may be blocked by 




posterior hypertrophies of the turbinated bodies or by 
polypi, cysts, fibroid tumors, or malignant growths, spring- 
ing from the posterior nares or from the vault of the 
pharynx. A somewhat common affection beginning gener- 



DISEASES OE THE NASOPHARYNX 1 89 

ally in childhood is hypertrophy of the phar)'iigcal or 
Luschka's tonsil. 

Adenoid vegetations or hypertrophy of the pharyngeal ton- 
sil (Fii^. 115) is an overgrowth of the normal adenoid tis- 
sue of the pharyni^eal vault. The affection is often associ- 
ated with hypertrophy of the faucial tonsils, and generally 
commences in childhood, but may be met with in patients 
of any age. 




Fig. 116. — Typic appearance in adenoid vegetations: boy ten years old (Frtihwald). 

Symptoms. — If the adenoid vegetations are at all large, 
they block up the posterior nares and compel mouth-breath- 
ing, the pinched nostrils and half-open mouth giving the 
face a vacant and well-nigh idiotic expression (Fig. 116), 
which ordinarily disappears as soon as nasal respiration is 
reestablished. However, if mouth-breathing be continued 
into adult life permanent deformity of the bones of the face 
and even of the chest sometimes results. Breathing is 
audible, even during the day, and there is always loud snor- 



190 DISEASES OF THE NOSE, THROAT, AND EAR 

ing during sleep. The voice is toneless, articulation is 
indistinct, and the hearing is often impaired. 

Treatmeyit. — Adenoid vegetations tend to no longer ob- 
struct nasal respiration as the individual passes into adult age 
and the nose and nasopharynx grows larger, but may, in the 
meantime, have produced irreparable injury to the ears, and 
even have altered the shape of the bones of the face. 
Application of Formula 33 to the postnasal space will some- 
times bring about a slow absorption of the hypertrophied tis- 
sue. In children, when the growth is not large, such applica- 
tions should be made by the surgeon two or three times a 
week, the parents in the meantime cleansing the nose night 
and morning with the spray from an atomizer containing 
an alkaline wash and afterward placing in each of the child's 
nostrils a mass of galUc acid ointment the size of a pea. 




7. — Lowenburg's postnasal forceps. 



The child should then lie on its back for a few moments 
until the ointment melts and runs into the nasopharynx. 
The gallic acid ointment should be of the strength of 
5 to 10 gr. to I ounce of vaselin, according to the age 
of the child. However, the only treatment adequate in the 
majority of cases is a thorough removal of the mass by 
surgical procedures. Often the masses of adenoid tissue 
are so soft that they can be scraped away by means of the 
forefinger introduced behind the soft palate. In adults 
Lowenburg's postnasal cutting forceps (Fig. 117) may be 
used ; the operator being careful to begin operating in the 
median line, and working from it in each direction until the 
entire mass is cut and torn away from its attachment, at 
the same time being exceedingly careful not to wound the 
orifices of the Eustachian tubes. 



DISEASES OE THE NASOPHARYNX I9I 

In children, or in adults in whom the pharyn<^cal tonsil is 
still comparatively soft, Gottstein's curet (Fig. 1 18) is a most 
efficient instrument. Young children should be seated in 
the lap of a nurse upon a piano stool opposite the operator, 
in the same manner as for an ordinary examination of the 
nose and pharynx. The nurse passes her arms beneath 
those of the child and places her hands, one on each side of 
the child's forehead, in such a manner as to control the 
movements of the head. The nurse then elevates her 
elbows so as to bring the child's arms into such a position 
that it is impossible for the child to reach its mouth with its 
hands. The curet is now passed behind the palate, and 
the handle of the instrument depressed until the outer edge 
of the ring is felt to rest against the septum. By sweeping 
the ring upward, backward, and downward against the 
pharyngeal wall the growth is brought within the curet and 
is scraped from its attachment. Without removing the 
instrument from the mouth the maneuver is quickly repeated 



Fig. 118. — Gottstein's improved nasal curet. 

at each side of the median line, in order to be certain that 
the major portion of the growth has been removed. The 
operation should be performed quickly, but with gentleness, 
little force being required to sever the growth from its 
attachment. 

The nurse then releases the child's head, and the operator 
passes his left arm around the child's head and thrusts his 
forefinger hard against the child's cheek, in such a manner 
that the cheek protrudes between the child's open jaws so 
as to form a most efficient mouth-gag. The operator then 
quickly passes the forefinger of his right hand behind the 
child's palate until the posterior edge of the septum is felt. 
The posterior nares, Rosenmuller's fossae, and the vault of 
the pharynx are inspected, as it w^ere, by the sense of 
touch. If any shreds of the growth remain they are removed 
with the finger-nail, scraping them from below, upward, 



192 DISEASES OF THE NOSE, THROAT, AND EAR 

and forward. Before removing his finger the operator 
should spare no pains to assure himself by the sense of 
touch not only that nothing remains to obstruct nasal 
respiration, but that Rosenmiiller's fossae are freed from 
any mass likely to interfere with the blood-supply of the 
Eustachian tubes. However, it should be borne in mind 
that the third tonsil is normal to the nasopharynx, and that 
it is neither necessary nor desirable to remove the whole 
of the adenoid tissue, but simply that portion which interferes 
with nasal respiration and the functions of the Eustachian 
tubes. In very young children the parts of the growth 
removed by the curet are either swallowed, expectorated, 
or blown through the nose. The hemorrhage following 
the operation is generally trifling and the after-treatment 
consists simply in keeping the parts clean with an antiseptic 
wash (Formulas i to 10). 

When a general anesthetic is employed it should be ether 
and not chloroform, because in this condition, the so-called 
" habitus lymphaticus " of Kalisko, chloroform is especially 
dangerous, somewhat numerous deaths having been reported. 
The ether should not be pushed to complete abolition of the 
reflexes, as even when only partially etherized the patient 
will probably become momentarily blue from partial 
asphyxia caused by the quantity of blood that generally 
enters the larynx. 

Ether is rarely if ever necessary to secure an adequate 
removal of the hypertrophy. However, the major portion 
of successful operators prefer to operate under ether 
anesthesia, stating that the operation then can be done more 
deliberately, and there is less danger of failure to remove 
all portions of the hypertrophy that are pathologic. The 
use of the forceps and the cureting should not be so radical 
as to expose the fibrous tissue overlying the verterbae or 
expose or tear loose the upper border of the superior con- 
strictor of the pharynx. During the operation the patient's 
head should be turned to one side or allowed to hang down- 
ward over the edge of the table in order to favor the escape 
of blood from the mouth and nose. 

The improvement in nasal respiration and in pronuncia- 
tion following the operation is immediate and pronounced ; 



DISEASES OF THE NASOPHARYNX 1 93 

and if hearing was impaired as the result of interference 
with the function of the Eustachian tubes, the acuteness of 
hearing rapidly improves after the operation. In adults the 
reaction from the operation is but trifling. Children, how- 
ever, sometimes complain for a few days that the throat is 
sore and that it hurts them to swallow. 

Thornwaldt's Disease or Chronic Bursitis. — The bursa 
of the pharyngeal tonsil was described by Luschka, and 
chronic inflammation of this structure was later eluci- 
dated by Thornwaldt, after whom the disease has been 
named. 

Symptoms. — When chronically inflamed the bursa of the 
third tonsil secretes a considerable amount of thick, tenacious 
mucus, globular masses of which may be hawked out by 
the patient from the pharynx several times a day. There 
are no other subjective symptoms in uncomplicated cases. 
When thoroughly cleansed by the postnasal syringe the 
bursa is discernible and may be explored to a variable 
depth by means of a probe suitably bent. 

Treatment. — The concensus of opinion seems to be that 
a permanent cure can only be effected by the radical 
destruction of the bursa by means of the galvanocautery or 
some other method, a most difficult matter to accomplish 
because of the anatomic situation of the bursa. However, 
almost complete cessation of the discharge, for the time 
being at least, can be brought about by thorough cleansing 
of the parts and applications to the interior of the bursa, by 
means of a cotton-tipped probe, of a solution of nitrate of 
silver (60 gr. to i ounce). 

In some cases the bursa can be cleansed by means of the 
syringe-tip 4, Fig. 38, suitably bent and inserted in the 
bursa either through the nose or the mouth. After wash- 
ing out the bursa with an alkaline solution, to which a 
portion of peroxid of hydrogen is added, a few drops of 
a 25 or 50 per cent, solution of argyrolmay be instilled into 
the cavity of the bursa through the same tube by means of 
syringe a, Fig. 38, two or three times a week. 



13 



194 I^^SEASES GF THE NOSE, THROAT, AiXD EAR 

DISEASES OF THE OROPHARYNX 

Acute Pharyngitis. — Acute pharyngitis is an acute inflam- 
mation of the mucous membrane and underlying structures 
of the pharynx. 

The synonyjus are acute sore throat; acute pharyngeal 
catarrh ; angina catarrhalis. 

Etiology. — Acute pharyngitis is generally the result of 
exposure to wet and cold, especially of persons of the 
rheumatic diathesis or of debilitated constitutions. It may 
also result from traumatism or the presence of a foreign 
body in the pharynx. Slight unilateral pharyngitis is not 
uncommon after an intranasal operation, and is probably 
due to a mild infection. It lasts for a day or two and then 
passes away. 

Pathology. — The inflammation is usually by no means 
evenly distributed, the glandular elements being always 
most affected. Their secretion is at first increased, but 
becomes after a time decreased, starchy, and glue-like in 
character. The tonsils are always involved to a greater or 
less extent, their inflammation becoming so great in some, 
instances as to mask the inflammation of adjacent structures. 

Symptoms. — The constitutional symptoms are usually 
trifling, a feeling of lassitude with slight fever. The throat 
feels sore, dry, and stiff The symptoms mayincrease until 
pain, especially when deglutition is attempted, becomes 
quite severe. The cervical glands are often swollen and 
painful to the touch. The voice is usually husky and a 
sensation as of a foreign body in the throat keeps the 
patient hawking and spitting. When the tonsils or larynx 
are seriously involved in the inflammation certain other 
symptoms are present, which will be described furtb.er on. 

Treatment. — A saline cathartic should be administered in 
sufficient quantities to secure one or more free movements 
of the bowels. A solution of nitrate of silver of the 
strength of i or 2 drams to i ounce of water should be 
freely painted over the inflamed lateral walls once or twice 
a day. It should be borne in mind that the application of 
solutions of the strength of i or 2 drams to i ounce of 
water is not painful, providing none of the solution is ap- 



DISEASES OF THE OROPIIA R YXX 1 95 

plied to the posterior wall. It is immediately followed by 
a sensation of relief and comfort, and tends to materially 
shorten the course of the disease. Applied to the posterior 
pharyngeal wall solutions of silver nitrate of over 5 or 10 
gr. to I ounce produce a sensation of dryness, stiffness, and 
discomfort. In this region a 10 per cent, solution of argy- 
rol sprayed upon the parts is preferable to the use of 
the nitrate. When acute pharyngitis is the result of 
the presence of a foreign body it should, of course, be 
at once removed and the inflamed pharynx treated as 
ordinary acute pharyngitis. When the rheumatic diathesis 
exists, the administration of guaiac (Formulas 138, 139) 
will be found to yield most excellent results, while in gouty 
sore throat colchicum should be prescribed. A spray of 
adrenalin chlorid (i : 5000) used every hour by the patient 
quickly relieves the congestion in most cases ; but other 
astringent sprays are sometimes equally efficient, the best 
probably is alunniol i dram to 4 ounces of water. If it is 
inconvenient for the patient to use an atomizer, lozenges 
may be prescribed. The camphomenthol lozenge (Formula 
142) is sedative and relieves the feeling of dryness and 
stiffness by increasing the secretions, and the same may be 
said of a lozenge of guaiac and potassium iodid. However, 
one of the most popular lozenges in this condition is that 
of guaiac and tannic acid (Formula 140). 

Simple chronic pharyngitis is a chronic inflammation of 
the mucous membrane of the pharynx, generally the result 
of chronic rhinitis. The disease is often complicated by 
inflammation of the follicles of the mucous membrane, and 
is then called follicular pharyngitis. 

Synonyms. — Chronic sore throat ; granular pharyngitis ; 
follicular pharyngitis ; chronic angina ; relaxed throat ; 
chronic catarrh of the throat. 

Treatment. — It is all important to bring about a cure of 
the nasal disease to the presence of which the pharyngeal 
malady is due. After a cure of the primary nasal affection 
has been brought about, simple chronic pharyngitis will get 
well almost without treatment. During the treatment of the 
nasal affection, however, applications should be made to the 
vault of the pharynx of Formulas 33, 34, or 35 in the 



196 DISEASES OE THE NOSE, THROAT, AND EAR 

following manner : A tongue-depressor (Figs. 10-12) should 
be used to hold down the tongue and the patient requested 
to try to breathe through his nose or say '' One," in order 
to relax the palatine muscles, when the application may be 
made without difficulty by means of an applicator, the end 
of which has been wrapped with cotton and bent to a 
suitable curve. Should, however, the palate lie closely in 
contact with the pharyngeal wall, considerable force will be 
required to carry the end of the applicator into the post- 
nasal space, while most of the solution with which the 
cotton on the end of the applicator has been saturated will 
be squeezed out and remain in the fauces. AppHcations 
made in such a manner tend rather to increase the existing 
inflammation than to subdue it, and it is always best to 
desist from making an application to the pharyngeal vault 
rather than employ force. When the uvula has become 
elongated or the mucous membrane of the fauces relaxed 
as the result of constant hawking, the daily application of 
the spray from an atomizer containing a solution of sulphate 
of copper (2 gr. to i ounce of water) will render material 
assistance in restoring the "relaxed throat" to a condition 
of health. In some instances it is necessary to amputate 
the relaxed and redundant mucous membrane at the tip of 
the uvula. 

Chronic follicular pharyngitis, or clergyman's sore throat, 
is a chronic pharyngitis characterized by inflamed and 
hypertrophied lymph-follicles. 

Pathology. — The pathology is similar to simple chronic 
phaiyngitis, except that the lymph-follicles are involved in 
larger numbers and to a greater degree. The subdivision 
of pharyngitis into pharyngitis and folHcular pharyngitis is 
a matter of convenience rather than fact, as in all simple 
inflammations of the pharynx the mucosa, the lymph- 
follicles, the submucosa, and often the muscles are usually 
involved in varying degrees. The watery portion of the 
secretions are decreased, and hence the expectorations are 
thick and glue-Hke from an increased proportion of mucin, 
epithelium debris, and mineral salts. 

Etiology. — The disease is generally the result of or part 
of a nasopharyngeal catarrh, excessive or faulty use of the 



DISEASES OF THE OROPIIAR YXX 1 97 

voice, excessive use of tobacco and distillctl liquors, the 
rheumatic or gouty diathesis, indigestion, and, in women, 
pelvic diseases. 

SymptoDLS. — The secretions are usually somewhat scanty 
and viscid, but voided with considerable difficulty. There 
is a short, frequent cough, distressing alike to patient and 
friends ; the so-called ** useless cough," because it accom- 
plishes nothing, either in ridding the throat of secretions 
or the constant pharyngeal irritation of which many of 
these patients complain. 

The appearance of the pharynx varies somewhat ; usually 
there is venous hyperemia over the entire surface, but 
greatest in the neighborhood of patches of hyperplastic 
follicles. In other cases the pharynx is less congested, the 
hypertrophied follicles projecting above the surrounding 
surface and surrounded by varicosities. Sometimes a num- 
ber of inflamed follicles coalesce in such a manner as to 
form a red, sore, and swollen area of considerable size. If 
such patches be situated close to the posterior pillars, so 
that they are rubbed aiid irritated by these folds of mu- 
cous membrane with every motion of the pharyngeal mus- 
cles, the sufferings of the patient amount to actual pain. 

Treatment. — The irritability of the mucous membrane 
covering areas of hypertrophied follicles can be decreased 
by lightly painting with a 60-gr. solution of nitrate of silver. 
However, care should be exercised to prevent the silver 
solution spreading over the surrounding mucous surface, 
because strong solutions of silver nitrate are irritating when 
applied to the posterior wall of the oropharynx. 

A certain amount of relief is experienced by the use of 
demulcent lozenges, either slippery elm, red gum, campho- 
menthol (Formula 142), or, better still in many instances, a 
lozenge of orthoform. 

Where the so-called useless cough is a prominent symp- 
tom it should be controlled by appropriate doses of sodium 
bromid. For this purpose as much as 10 or 15 gr. after 
meals and at bedtime will be required. The matter is of 
considerable importance, as the constant coughing greatly 
irritates the pharynx and increases the existing inflammation. 

The condition of the tonsils should be carefully examined. 



DISEASES OF THE NOSE, THROAT, AND EAR 



Often they are slightly hypertrophied and the crypts contain 
cholesteatomatous masses. The removal of any con- 
comitant disease of the nasal cavities also will have much 
to do with the success of treatment. 

With many practitioners the radical de- 
struction of the diseased glands by means 
of the galvanocaiitcry is a favorite method 
of treatment. A very small cautery-knife 
should be selected, and great care should, 
be exercised not to burn too deeply, or the 
resulting scar will cause more trouble than 
the original disease. It is unwise to apply 
the galvanocautery-knife to more than two 
or three hypertrophied follicles at one time, 
or the treatment may be followed by a 
somewhat sharp attack of acute pharyngitis. 
Emil Mayer of New York curets away 
the offending follicles by means of a special 
curet (Fig, 1 19). By this method of treat- 
ment, which is much less painful than the 
use of the galvanocautery, all the hyper- 
trophied follicles are removed at a single 



Atrophic pharyngitis is an atrophic condi- 
tion of the mucous membrane and sub- 
mucous tissues of the pharynx. 

The synonyms are pharyngitis sicca ; dry 
pharyngitis. 

Etiology. — Atrophic pharyngitis generally 
results from long contact with the irritating 
discharges of nasal catarrhs. It frequently 
exists v/hen atrophic rhinitis is present, being 
probably the result of an extension of the 
atrophic process to the pharyngeal mucous 
membrane. A dry condition of the faucial 
mucous membrane, amounting almost to 
pharyngitis sicca, is found in all mouth- 
breathers, but disappears spontaneously as soon as the nose 
has been rendered sufficiently patulous. 

Symptoms. — The patient complains of his throat feeling 



Fig. iig.^Emil 
Mayer's pharyngeal 
curet. 



DISEASES OE 77JE OROPlfARVNX 1 99 

dry and stiff. Upon inspection, the mucous membrane of 
the throat appears h'ght colored, thin, and as if varnislied. 
Frequently the mucous membrane is so thin that the outHne 
of each cervical vertebrae can be distinguished. Sometimes 
masses of inspissated mucus, perhaps dark colored from the 
dust inhaled, and swept into ridges by the motions of the 
soft palate, are seen adhering to the atrophied mucous 
membrane. 

Treatmc7it. — Attention should be mainly directed to the 
condition of the interior of the nose, because it is the 
experience of most rhinologists that when a cure of the nasal 
affection has been brought about the concomitant throat 
disease will get well almost without treatment. The general 
health should receive attention and, if necessary, tonics 
should be prescribed ; while a sluggish condition of the 
bowels may indicate the use of saline laxatives. If atrophic 
rhinitis has caused the affection, plugs of cotton, previously 
mentioned as useful in atrophic rhinitis, should be made 
long enough to project somewhat from the posterior nares 
into the pharynx, while a weak solution of nitrate of silver 
(gr. v-xv to f5J) should be applied to the atrophied mu- 
cous membrane, both above and below the soft palate, 
to stimulate the atrophied glands to increased secretion and 
bring about renewed growth of the atrophied structures. 
In certain cases it may be advisable to give for a short time 
some drug like iodid of potassium, phosphorus, or muriate of 
ammonia to stimulate the pharyngeal secretions. A pill 
containing j-^ gr. of phosphorus may be given after meals 
or the lozenge of guaiac and iodid of potassium, one every 
three or four hours, may be ordered. It should be borne 
in mind that the stomach does not tolerate well any lengthy 
administration of these remedies and \\\ most cases their use 
is best avoided. 

Mycosis of the pharynx is a parasitic disease involving in 
most cases the faucial, pharyngeal, and lingual tonsils, 
although other parts of the phaiyngeal mucous membrane 
do not escape in some instances. It is characterized by 
little white, conic elevations, sometimes as large as a grain 
of rice, due to the presence of fungi of the class mycosis, 
most frequently the leptothrix buccalis. 



200 DISEASES OF THE NOSE, THROAT, AND EAR 

Etiology. — Leptothrix is so frequently found in the 
secretions of the mouth that it might almost be termed a 
normal constituent. It is especially prevalent in the mouths 
of individuals with carious teeth, accumulations of tartar, 
etc. Why it should in some individuals cause the horny, 
chalk-white growths characteristic of mycosis is not well 
understood. 

Pathology. — Leptothrix penetrates the lacunae of the 
tonsils and the glands of the mucous membrane of the 
pharynx Multiplication of the threads takes place, so that 
they grow through the epithelial cells and appear on the free 
surface of the mucous membrane, where they appear as 
whitish masses, generally cone shaped, the base of the cones 
adhering tightly to the mucous membrane and their apices 
projecting into the pharynx. Under the microscope the 
cones are seen to consist of granular material, a few 
epithelial cells, and numerous threads of leptothrix. These 
threads when stained are seen to be jointed and contain 
numerous spores. 

Symptoms. — A few masses of leptothrix may be present 
in the pharynx without causing any symptoms whatever. 
Under such circumstances the masses may be discovered, 
usually upon the tonsils, while examining the throat of a 
patient. Usually, however, patients with leptothrix com- 
plain of a tickling sensation in the pharynx and spasmodic 
cough. 

Treatinent. — On the tonsils and other easily accessible 
portions of the pharynx the little masses should be grasped 
one by one and pulled off. They are attached somewhat 
firmly and considerable force and a suitable forceps is 
necessary to remove them. The smallest size of Farnham's 
alligator-forceps or, better, Hartmann's ear forceps answers 
the purpose better than most, because so firmly adherent 
are the little masses that they are apt to slip from the grasp 
of forceps with smooth jaws. After the removal of the 
little masses the mucous membrane where they grew should 
be brushed with nitrate of silver (60 gr. to i ounce of 
water). In inaccessible localities, like the base of the tongue 
and beneath the epiglottis, leptothrix is better attacked with 
the galvanocautery-knife rather than the forceps. A very 



DISEASES OF THE ORorilAKYNX 20I 

small knife, suitably curved, should be selected, and the 
current should be powerful enough to instantly heat the 
very small platinum wire white hot, when it is applied to 
the leptothrix cone, and destroy it before the heat has time 
to burn the surrounding mucous membrane by radiation, 
as would be the case if a larger wire, heated only red hot, 
were used. 

As only a limited number of leptothrix cones can be 
destroyed at a sitting, the treatment in cases where they are 
very numerous is necessarily somewhat tedious. Some of 
the cones re-form after their removal. Applications of 
silver nitrate (60 gr. to i ounce) prevents this to a consider- 
able extent, and occasionally when applied to the surface 
where leptothrix is growing will cause the cones to disap- 
pear after frequent applications. Occasionally the growths 
disappear spontaneously. 

Erysipelas of the Pharynx. — Erysipelas of the face some- 
times extends to the pharynx or the disease may originate 
in the pharynx. 

Etiology. — Like erysipelas elsewhere the disease is the 
result of the presence of Fehleisen's erysipelas streptococcus. 

Pathology. — The fauces are dusky red and swollen. 
Vesicles form on the surface filled with seropus. The 
disease is evidently contagious under certain circumstances, 
as epidemics have been described, notably that in America 
in 1842. Erysipelas mayextend to the middle ear through 
the Eustachian tube or to the lungs through the larynx. 

Prognosis. — In the milder cases the prognosis is good. 
The phlegmonous variety of the disease is almost invariably 
fatal. 

Treatment. — The treatment is that of erysipelas elsewhere. 
Large doses of the tincture of the chloricl of iron (20 to 30 
drops in water) should be given- every three hours, with 
strychnin, 3^ gr., if necessary. The nose and pharynx 
should be sprayed with an alkaline wash every three hours, 
followed by adrenalin solution (i : looo). The spray of 
adrenalin should be repeated at intervals of a few moments 
until the parts have somewhat blanched, after which they 
should be covered with a 20 per cent, solution of argyrol 
by means of the spray from an atomizer, 



202 DISEASES OF THE NOSE, THROAT, AND EAR 

Phlegmonous pharyngitis is an acute infection of the phar- 
ynx, phlegmonous in character, extending to the deeper 
structures and usually terminating fatally in from five to ten 
days. 

Etiology. — The disease usually attacks those of broken- 
down constitutions or the aged. There is usually a history 
of slight traumatism, followed by virulent infection with 
some pus-producing organism. 

Pathology. — There is an enormous swelling of the fauces 
at an early stage of the disease, followed by a speedy for- 
mation of pus, which infiltrates the surrounding tissues and 
produces pyemia. The organism present in the pus is 
usually the streptococcus pyogenes aureus, or there may be 
a mixed infection. 

Symptoms. — The onset of the disease is sudden. The 
temperature rises to 103° or 104° F. The throat is sore and, 
as in a case observed by the author at the Philadelphia 
Hospital, the swelling may be so rapid as to necessitate 
tracheotomy within twenty -four hours to prevent suffocation. 
There are symptoms of general infection. There is a 
clammy perspiration, great weakness and debility, often fol- 
lowed by collapse and death. 

Treatment. — Local treatment is of little avail. If as- 
phyxia is imminent, tracheotomy should be resorted to, 
suspected abscesses should be opened, either externally 
through the skin by a free incision or in the pharynx if fluc- 
tuation is detected. Hourly hypodermic injections of anti- 
streptococcus serum should be given, with large hot enemas 
of normal salt solution every three or four hours. Stimu- 
lative enemas also will be necessary if the patient is unable 
to swallow, with hypodermics of strychnin (gi^ gr.) every 
three or four hours to prevent collapse. 

Simple Ulcer of the Pharynx. — Ulcers of the pharynx are 
localized areas of necrosis. 

Etiology. — Most ulcers of the pharynx are either syphiHs, 
epithelioma, or tuberculosis. However, there is an ulcera- 
tion of the pharynx or fauces, generally the result of mixed 
infection from the ever-present bacteria of the mouth, that 
is occasionally observed, generally in the feeble or debili- 
tated or those suffering from some error of metabolism. 



DISEASES OE THE OROPHARYNX 203 

Some cases arc the result of traumatism followed by infec- 
tion. 

The symptoms vary according to the size and location 
of the ulceration. The pain will be severe, especially 
during swallowing, if the ulceration is so localized as to be 
irritated by the action of the faucial muscles. Under such 
circumstances there may be regurgitation of food through 
the nose. If the inflammation extends to the larynx there 
will be hoarseness or loss of voice, and if the tissues about 
the Eustachian tubes are involved by the inflammation, 
earache. Some of the older writers attached a consider- 
able amount of diagnostic importance to the fact that in 
epitheliomatous ulceration of the pharynx and larynx pain 
shooting up into the ear was a common symptom. How- 
ever, this symptom occurs in any pharyngeal ulceration, 
but is less common in syphilitic and tuberculous ulcers. If 
the ulceration is long continued there will be progressive 
loss of flesh. 

Upon inspection the ulcer is seen upon the pharynx 
either medianly or laterally, similar in appearance to ulcera- 
tions occasionally seen upon the tonsils. It may be round 
or oblong. The edges are usually well defined and the 
ulcer may be filled with sloughing tissue, or the floor of the 
ulcer may be comparatively clean and so deep that when 
situated medianly the bone of the vertebra is bared. 

Diagnosis. — The diagnosis in ulceration of the pharynx 
rests between syphilitic, tuberculous, epitheliomatous, and 
simple ulceration. The administration for a week or ten 
days of lo to 20 gr. of iodid of potassium after meals and 
at bedtime will clear up the diagnosis as far as syphilis is 
concerned. There is also the method of Justis : A hemo- 
globin estimate is made before and after a mercurial inunc- 
tion. If twenty-four hours after the inunction there is a 
decrease of 10 to 20 per cent, hemoglobin, the disease is 
probably syphilis. 

Cancer of the pharynx is differentiated by examining 
microscopically a small section removed from the edge of 
the ulcer, and tuberculosis by the tuberculin-test, the con- 
dition of the patient, or by microscopic examination of the 
sputum. 



204 DISEASES OE THE NOSE, THROAT, AND EAR 

Treatment. — The treatment of syphilitic, epithehomatous, 
and tubercular ulcerations has been described elsewhere. 
In simple ulceration tonics and lo or 15 gr. of pepsin should 
be given. The ulcer should be cleansed each day with 
Dobell's solution or peroxid, and an application made of 
nitrate of silver (60 gr. to i ounce of water), after which 
the floor of the ulcer should be dusted either with ojr thoform 
or a mixture of iodoform, tannic acid, bismuth, and mor- 
phin (Formula 58). Both the orthoform and the above 
powder are analgesic and relieve pain. They are also anti- 
septic and adhere to the ulcerated surface sometimes for 
hours. Of the two, the compound iodoform and tannic 
acid powder gives the better results. 

Syphilitic pharyngitis is an inflammation of the pharynx 
due to the presence in the system of the syphihtic poison. 

The primary sore is not infrequently seen. Mucous 
patches are by no means rare, while gummata or their 
characteristic cicatrices are very often met with in the 
pharynx, especially in dispensary practice. 

Sympto77is. — In primary syphilis, examination shows a 
whitish abrasion, soon followed by swelling of the glands 
about the angle of the jaw. Secondary lesions may present 
either the form of mucous patches or erythema, characterized 
by a diffuse redness of the entire fauces or, more commonly, 
in the milder attacks, by a broad red line extending upward 
upon each of the anterior pillars, and ending abruptly and 
symmetrically at the root of the uvula. Mucous patches 
and erythematous patches in the throat are almost always 
symmetric ; that is, both sides of the throat are attacked 
in corresponding localities by similar lesions, while tertiary 
lesions do not as frequently present this symmetry. Gum- 
mata more frequently involve the tonsils or soft palate 
than other parts of the throat. A gumma may be absorbed 
under treatment or, breaking down, result in a rapidly 
spreading ulceration. When an ulcerating gumma is situated 
upon the posterior wall of the pharynx, the cervical 
vertebrae or even the cervical cord itself may finally become 
involved, and a fatal issue result. In such cases also the 
utmost care is required to prevent union of the soft palate 
and uvula to the pharyngeal wall, when the ulceration has 



DISEASES OE THE OROPHARYNX 205 

also involved the posterior surface of the palate. Where 
union has actually taken place, it is almost impossible at 
any subsequent period to permanently restore satisfactory 
communication between the oropharynx and nasopharynx 
by any operation, because of cicatricial contraction after the 
operation. 

Treatinc7tt. — In pharyngeal syphilis, as in syphilis else- 
where, constitutional treatment is of primary importance, 
and the same remedies may be employed internally as 
already recommended in the treatment of nasal syphilis 
(Formulas 73-75). If the symptoms are urgent, the 
hypodermic method of administering mercury should be 
employed, as it gives the most speedy results. Local treat- 
ment consists in maintaining perfect cleanliness of the 
diseased parts and stimulating mucous patches and ulcera- 
tions to heal by daily applications of the acid nitrate of 
mercury, diluted with 5 parts of water, and the application, 
by means of the powder-blower, of a small quantity of 
Formula 58 or 59. 

Tuberculosis. — The presence of the tubercle bacilli is 
sometimes demonstrable by means of the microscope in the 
secretions of a mild chronic pharyngitis of nurses and at- 
tendants in the tuberculous wards of hospitals. Primary 
tuberculous pharyngitis with marked lesions is rare. Second- 
ary tuberculous pharyngitis in phthisic patients is somewdiat 
common, and is usually observed as ulcerations resembling 
those of tertiary syphilis. 

Infection probably reaches the pharynx through some 
locaHzed solution of continuity from the secretion of the 
tuberculous lungs. Tubercles form in the submucosa which 
finally break down and ulcerate. 

Treatment. — In cases where there are no marked lung 
lesions and the diagnosis is obscure, antisyphilitic remedies 
should be administered until the surgeon has satisfied him- 
self by the " therapeutic test " that the disease is not syphilis. 
The hemoglobin-test of Justis may be employed to assist 
in the diagnosis. When ulceration has occurred the ulcers 
should be cleansed with peroxid of hydrogen, cocainized, 
and touched wdth lactic acid once in two or three days. 
As these apphcations are somewhat painful, even after 



2o6 DISEASES OF THE NOSE, THROAT, AND EAR 

cocainization, it is well not to employ a stronger solution 
than 25 per cent, until the amount of pain and reaction 
caused by the application has been ascertained, after which 
the concentrated syrupy acid may be employed if deemed 
advisable. Rarely is it necessary to employ the curet, 
and the prognosis as regards heahng is favorable. 

Lupus vulgaris is a form of inflammation involving the 
mucous membrane and submucous tissues of the pharynx, 
generally ending in ulceration due to the presence of the 
tubercle bacilli. 

Etiology. — The disease is said to be more common on the 
continent of Europe than in America. It occurs in tuber- 
culous families and* in those frequently brought into contact 
with tuberculous patients. 

Symptoms. — -The general condition of the patient may be 
that of good health. The disease is insidious and causes 
little annoyance until the ulcers are sufficiently large to 
interfere with the functions of the parts. Early in the 
disease soft reddish nodules about the size of sago grains 
appear on one or both sides of the pharynx. These finally 
break down, producing ulcers which may spread to the 
pillars of the fauces, the palate, or the larynx, one portion 
of the ulceration healing while another is extending. 

Pathology. — Portions of the diseased tissue cureted away 
show, under the microscope, typic tuberculous giant cells. 
However, tubercle bacilli are found only in small num- 
bers and with difficulty. 

Diagnosis. — The ulcerative stage may be mistaken for 
herpes, syphilis, or epithelioma. The short duration of 
herpes and the more rapid progress of epithelioma should 
serve to differentiate the disease from lupus. In suspected 
syphilis the " therapeutic test " serves to clear up the 
diagnosis. The tuberculin-test gives a positive reaction, 
causing local hyperemia and some rise of temperature, 
which subsides in twenty-four hours. The microscope 
shows typic tubercle giant cells. 

Treatment. — The parts should be thoroughly cureted and 
the solid stick of nitrate of silv^er applied. Cures have been 
reported by the use of the ;r-ray. 

Glanders, farcy, or equinia is a contagious, specific disease 



DISEASES OE THE OROPHARYNX 207 

with both local and constitutional symptoms, usually con- 
tracted from infected horses. It is due to the presence of 
the bacillus mallei. 

Symptoms and Course. — Pemphigus-like vesicles appear 
at the point of infection, usually the face. The vesicles 
ulcerate and the parts sometimes become gangrenous. 
Metastatic abscesses occur on the face, trunk, and extrem- 
ities. In milder cases vesicles and abscesses heal in a short 
time and the patient recovers. In severer cases there is 
marked prostration, with rapid rise in temperature, head- 
ache, pain on swallowing, dryness of the throat, and enlarge- 
ment of the submaxillary and cervical glands. Foul-smell- 
ing pus flows from the nose and pharynx and a purulent 
bronchitis is usually present. The more severe form of the 
disease is usually fatal. 

Treatment. — Local treatment consists in cleansing the 
nasal and pharyngeal mucous membranes with diluted 
peroxid of hydrogen and detergent washes and then spray- 
ing the nose and pharynx with carbolated albolene. The 
systemic treatment should be supportive. There is no 
known specific remedy for the disease. 

Actinomycosis is a parasitic, infectious, inoculable disease, 
first observed in cattle and later in man. It is due to the 
presence of the leptothrix streptothrix or ray fungus. The 
most frequent and curable form of the disease is when 
abscesses form about the jaws or fauces. When the parasite 
has found a nidus in the lungs or digestive tract the disease 
is fatal. 

Etiology. — Actinomycosis is the result of inoculation with 
the ray fungus, which gains entrance to the mouth, pharynx, 
or nose from ingesta or inspired air. The disease may 
originate primarily in either of these cavities and, more 
rarely, in the larynx or ear. 

Pathology. — A slow swelling occurs, usually first at the 
angle of the jaw, which renders swallowing difficult. Upon 
inspection, if suppuration has not already occurred, the mass 
will be found to be firm to the touch and involve one or 
more of the cervical glands or the tonsils. At the seat of 
infection a nodule occurs which breaks down and discharges 
pus containing typic granular masses, which, upon com- 



208 DISEASES OF THE NOSE, THROAT, AND EAR 

pression, forms star-like bodies, yellowish in color, with a 
center which stains blue with Mallory's stain. 

Symptoms. — The symptoms and pathology of the disease, 
as affecting the human tonsils, was first described by 
Jonathan Wright (1904). The symptoms are those of gran- 
ulating, painless abscess with general systemic infection. 
The laryngologist is usually first consulted by the patient 
for catarrh and hypertrophied tonsils. One or more crypts 
of the tonsils may be suppurating and lined with granula- 
tions. 

TreaUnent. — The affected tonsil or tonsils should be 
amputated. Where this cannot be done the application of 
the galvanocautery is the best form of treatment. Each 
nodule or suppurating crypt should be thoroughly destroyed. 
Abscesses occurring in localities other than the tonsils 
should be opened, cureted, and cauterized with the solid 
stick of nitrate of silver. lodid of potassium in large doses 
is stated to inhibit the growth of the ray fungus, and Sawyer 
reports favorable results from the injection into tumors of 
from 15 to 30 minims of a i per cent, solution of the 
iodid. 

Retropharyngeal abscess is an abscess of the posterior 
phar>mgeal wall. It may be hidden above and behind 
the soft palate and require the rhinoscope to ascertain its 
outHne ; it may be situated opposite the larynx, and only be 
seen in its entirety with the laryngoscope, or it may be situ- 
ated in such a manner as to be hidden by one of the posterior 
pillars of the pharynx. However, the most common seat 
of abscess is the posterior wall of the pharynx opposite the 
oral cavity on one side or the other of the median line. 

Etiology. — Abscess may occur as the result of phleg- 
monous inflammation of the cellular tissue of the pharynx, 
scrofula and syphiHs being predisposing causes. Traumatism 
and necrosis of the vertebrae are sometimes causes of the 
affection. 

Symptoms. — There is usually but slight systemic disturb- 
ance. Chilly sensations may perhaps be complained of, 
but local symptoms are usually the first to attract attention. 
When the abscess is situated high up upon the pharyngeal 
wall, a sensation as of a foreign body causes almost constant 



DISEASES OE THE OROPHARYNX 209 

hawking and spitting, while thcrcmay be present obstructed 
nasal respiration with more or less pain and tinnitus. When 
the abscess is opposite the larynx, dyspnea is a marked 
symptom, appearing in " spasms " which may endanger the 
patient's life, while swallowing of liquids or solids is dan- 
gerous, owing to their frequent passage into the larynx. 
In the case of an eighteen-months'-old child seen in consul- 
tation by the writer, the mere attempt to introduce a tongue- 
depressor into the mouth was followed by collapse and 
apparent death. The child's life was saved only by a rapid 
tracheotomy with the only available instrument, a penknife. 
The next day after the operation the cause of the obstructed 
respiration was discovered to be a retropharyngeal abscess 
situated low down in the pharynx opposite the larynx. The 
abscess was opened and the child made a good recovery. 

An abscess in the pharyngeal wall opposite the oral 
cavity presents none of these symptoms unless very large. 

T}'cat})ic)it. — Left to itself, a retropharyngeal abscess will 
discharge either into the throat or at some more remote 
point, but as soon as a diagnosis is estabUshed an incision 
should be made into the abscess at its lowest part, and the 
opening maintained patulous by the daily passage of a 
probe as long as necessary to bring about a cure of the 
affection. 

Prognosis is favorable except in those cases where the 
spinal vertebme are involved. In all operations upon the 
posterior wall of the pharynx it should be borne in mind 
that a large artery is occasionally found in this position, 
probably the vertebral, which sometimes enters its osseo- 
fibrous canal as high up as the fourth or even second 
vertebra. It has been seen to leave its canal at the third 
vertebra, to re-enter it at the atlas. 

Tumors. — Any of the varieties of tumor found in other 
parts of the body may occur in the pharynx. They are 
most frequently located in the lateral walls and may involve 
the surrounding structures. In the following order of 
frequency there is found in the pharynx gumma, sarcoma, 
carcinoma, lupus, papilloma, cyst, fibroma, osteoma, en- 
chondroma, adenoma, and aneurism. 

Symptoms. — When the growth is large it may become an 
14 



210 DISEASES OF THE NOSE, THROAT, AND EAR 

obstruction to deglution or even respiration. In carcinoma 
and ulcerating lupus pain is also present, which in many 
instances radiates into the ean 

Treatment. — Except in the case of gumma, the treat- 
ment of which has been already described, early extirpation 
with the knife, galvanocautery, or snare should be practised. 

NEUROSES OF THE PHARYNX 

The more common neuroses of the pharynx are anes- 
thesia, hyperesthesia, paresthesia, neuralgia, and paralysis, 
either unilateral or complete. 

Anesthesia, as encountered in the office of the rhinologist, 
is most often the result of hysteria. The pharyngeal re- 
flexes are abolished ; there is a more or less complete loss 
of pharyngeal sensation when the parts are touched with a 
cotton-tipped probe. The condition is observed in cases of 
progressive bulbar paralysis and in the general paralysis of 
the insane. 

Treatment. — ^Treatment depends on the cause of the con- 
dition. In hysteria it may be advisable to use the strong 
galvanic or induced current with strychnin internally, possi- 
bly in increasing doses. 

Hyperesthesia is generally the result of some disease of 
the nose and nasopharynx that has rendered the secretions 
viscid and sticky, so that frequent hawking is necessary to 
dislodge them. The excessive use of tobacco, especially 
chewing-tobacco, will produce the same condition. In some 
cases of hyperesthesia of the pharynx the reflexes are in- 
creased to such an extent that barely touching the pharynx 
is sufficient to produce emesis. There is, of course, hyper- 
esthesia of the pharynx in practically every case of acute 
pharyngitis. 

Treatment. — Cessation of the excessive use of tobacco or 
cure of the nasopharyngeal catarrh that has produced the 
condition is ordinarily sufficient to reduce the hyperesthesia 
to normal and diminish the reflexes. Temporary relief is 
aflbrded by the administration of sodium bromid in doses 
of lo or 15 gr. three times a day. When the reflexes are 
not increased to an extent to produce vomiting whenever 
the pharynx is sprayed, the patient should spray his pharynx 



DISEASES OF THE OROPJIARYNX 211 

three or four times a day with an atomizer containin;^ a 
solution of sulphate of copper (2 to 5 <^^r. to I ounce of 
water). 

Paresthesia is most frequently manifested as a sensation 
as of a small foreign body in the pharynx. This sensation 
and burning, itching, or tickling, as well as spasm of the 
pharyngeal muscles, the well-known " globus hysterias," 
are not uncommon in hysteric females. However, in the 
larger proportion of these so-called hysteric cases some 
lesion will be found to account for the symptoms if the 
pharynx be carefully inspected. The most common lesions 
are inflamed follicles or an erosion on either side of the 
pharynx, posterior to the posterior pillar, or in any other 
position where two folds of mucous membrane rub together 
in deglutition. 

Treatment. — The symptoms are usually quickly relieved 
by 10 or 15 gr. of bromid of sodium after meals and at 
bedtime. After relief has been secured by the use of the 
bromid, a general tonic treatment should be prescribed for 
building up the nervous system — rest, iron, quinin, phos- 
phorus. Pil. sumbul comp., one or two after each meal, 
frequently yields very satisfactory results. When inflamed 
follicles or any erosion is found in a position where it is 
irritated by each movement of the pharyngeal muscles, it 
should be touched every day or two with a 60-gr. solution 
of nitrate of silver. 

Paralysis of the Pharynx. — Etiology. — Paralysis of the 
pharynx may result from diphtheria or syphilis, or be the 
result of a cerebral affection involving the nerves that supply 
the pharyngeal muscles. Transient paralysis of the palate, 
either unilateral or bilateral, is common as the result of 
diphtheria ; more rarely are the pharyngeal muscles also 
paralyzed in severe cases. 

Pathology. — One or both sides of the pharynx may be 
involved, and one or all three of the pharyngeal con- 
strictors be paralyzed, as well as the velum palati ; but 
paralysis of the soft palate, either unilateral or bilateral, 
occurs independently as a "reflex" in ethmoiditis. 

Symptoms. — Difficult deglutition ; liquids being more 
easily swallowed than solids, but more frequently passing 



212 DISEASES OF THE NOSE, THROAT, AND EAR 



into the larynx ; or, when the soft palate is also paralyzed, 
both solids and fluids may be forced into the posterior nares 
through the efforts of the tongue to assist deglutition. 

Treatment. — The central cause of the affection should 
be carefully sought and treated. In suitable cases strychnin, 
in gradually increasing doses until the limit of toleration 
has been reached, will do good ; while arsenic and tonics 
are especially valuable where the paralysis is of diphtheritic 
origin. 




Schroeter's forceps. 



Foreign bodies of two classes are found in the pharynx : 
First, those whose bulk does not allow them to pass 
through the esophagus, and secondly, sharp-pointed objects, 
hke pins, needles, fish-bones, etc., that are forced into the 
pharyngeal walls by contraction of the constrictor muscles. 

Symptoms. — Large objects may cause death by holding 
down the epiglottis. Sharp-pointed objects cause a prick- 
ing sensation, sometimes felt at two places in the pharynx, 
as in the case of a pin or needle. Localized spots of inflam- 
mation, when situated low down upon the pharyngeal wall, 
give rise to the sensation of a foreign body, and this fact, 



DISEASES OE THE OROrHARYNX 2l3 

as well as the imaginary foreign body of hysteric women, 
should be remembered after an unsuccessful search for a 
foreign substance in the pharynx. 

Treatment. — It is not always possible to use the laryngo- 
scope to advantage when the foreign body is situated low 
down in the pharynx, and in such cases the finger should 
be introduced into the pharynx, and if a foreign body be 
felt an effort should be made to scratch it loose with the 
finger-nail and withdraw it. When the offending substance 
can be seen, a pair of forceps, either straight or curved 
(Fig. 120), according to its position, should be used to with- 
draw it. It should be remembered that after the removal 
of a foreign body sometimes a sensation as of its presence 
remains for some days. 



THE TONSILS 

DISEASES OF THE TONSILS 

Acute tonsillitis is an inflammation of the tonsils and 
adjacent structures. There are two common varieties — the 
croupous and the phlegmonous. 

The synonyms are quinsy ; amygdalitis ; cynanche ton- 
sillaris ; angina tonsillaris ; angina faucium ; follicular ton- 
sillitis ; croupous tonsillitis. 

Etiology. — The croupous variety of the disease (Fig. 121) 
is the result of infection, the disease being infectious, but 
probably not contagious. The phlegmonous variety (Fig. 
123) is apparently often the result of exposure to cold and 
wet. Recurrent attacks of peritonsillitis are often the result 
of chronic mflammation of the tonsils, with or without 
hypertrophy. The cheesy secretion that is retained within 
the crypts (Fig. 122) becomes from time to time a source 
of infection and inoculates either the tonsillar structure 
itself or, more frequently, the surrounding cellular tissue. 
Deposits of fetid material between the tonsil and the anterior 
pillar, when the tonsil is partially adherent to it, also are 
capable of inoculating the adjacent cellular tissue and 
causing recurrent attacks of peritonsillar abscess. For 
these reasons excision of hypertrophied tonsils is not always 
followed by a cessation of recurrent attacks of quinsy, unless, 
after the excision, care is taken to destroy with the galvano- 
cautery-knife all crypts that may remain in the stump of 
the tonsil and dissect the latter loose from the faucial 
pillars, should it be adherent, in order to destroy all recep- 
tacles capable of retaining putrid secretions. 

However, recurrent quinsy occurs in individuals who be- 
tween the attacks have apparently normal tonsils. In such 
cases the rheumatic and gouty diathesis also plays its part 

214 



J) I SK ASKS OF 'J HE TONSILS 



215 



in the production of an attack of acute tonsillitis, l^hlcg- 
monous tonsillitis is a disease of adolescence and early adult 
life, and does not so frequently attack individuals who arc 
over thirty-five years of age. 

Pathology. — The inflammation may be only superficial 
(erythematous tonsilljtis) or may involve the parenchyma 
of the gland (parenchymatous tonsillitis). When the inflam- 
mation is deep seated, an abscess may occur either in the 
tonsil or more frequently in the cellular tissue about the 
tonsil, but the brunt of the inflammation is frequently borne 
by the crypts of the tonsils, which pour out an abundant 
fibrinous secretion, which, adherincr to the surface of the 





Fig. 121. — Follicular tonsillitis. 



A 

Fig. 122. — Crypts in cases of 
tonsillitis : A, Acute lacunar ; B, 
chronic hypertrophic ; a. surface- 
epithelium : h, accumulated con- 
tents of crypt ; c, lymphoid follicles 
surrounding crypt. (Kaufmann.) 



tonsil, presents somewhat the appearance of a diphtheritic 
membrane (croupous tonsillitis). 

Diagnosis. — By croupous tonsillitis is meant an inflamma- 
tion of the tonsil, originating in the crypts and accompanied 
by the formation of a pseudomembrane which, at first con- 
fined to the neighborhood of the crypts, often finally extends 
over the entire tonsil or tonsils, if both be involved. In 
typic cases occurring in ^<y/<://.y there is usually no difficulty 
in distinguishing by the unaided eye the difference between 
such a membrane and the more yellowish, thicker, and some- 
times seminecrotic membrane of diphtheria. The croupous 
membrane is thin, white, perhaps opalescent, and can some- 
what readily be wiped away, a small piece at a time, by 



2l6 DISEASES OF THE NOSE, THROAT, AND EAR 

means of a cotton-tipped probe. Ordinarily it does not 
extend beyond the tonsils. 

In some instances, however, in the case of young children, 
diagnosis by the unaided eye between the two affections is 
by no means easy. The struggles of the child allow only 
a momentary glance at the parts and for the same reason 
some bleeding may occur in the effort to remove a part of 
the membrane. Occasionally in such cases a thin opalescent 
patch occurs upon the anterior pillars or elsewhere in the 
neighborhood of the tonsil, whose appearance is very 
deceptive. 

Ordinarily the temperature is higher in croupous or follic- 
ular tonsillitis than in diphtheria, but some cases, after a tem- 
perature of 103° F. or thereabouts for the first twenty-four 
hours, assume the characteristic lower temperature of mild 
diphtheria. In rare instances albiuninuria occurs during 
an attack of croupous tonsillitis in children, and several 
competent observers have reported cases of croupous 
tonsillitis followed by paralysis of the soft palate. 

Rare in the adult, at least a croupy cough is to be ex- 
pected in young children with follicular tonsillitis, and 
sufficient laryngeal stenosis to require intubation is not 
impossible. 

The disease is undoubtedly infectious, but some doubt 
exists as to its being contagious. Under the microscope 
several varieties of bacteria are often found in the pseudo- 
membrane, the most constant being the streptococcus. As 
the streptococcus and other varieties of bacteria sometimes 
exist in the superficial layer of diphtheritic memibranes and 
mask the presence of the Klebs-Loffler bacillus, which is 
present in the deeper parts of the pseudomembrane, even 
culture-tests are not always reliable as a means oi diagnosis. 

Symptoms. — Both in croupous and phlegmonous tonsillitis 
dryness and stiffness in the throat is first noticed, soon 
followed by dysphagia. There is a chill or chilly sensa- 
tions, and pain in the legs and back, headache, and fever. 
As the disease progresses the sufferings of the patient be- 
come severe. The dryness of the throat causes frequent 
attempts at swallowing saliva, which are exceeding painful. 
The mouth can be opened only with pain and difficulty and 



DISEASES OE THE TOXSILS 21/ 

speech becomes almost unintelligible. The tongue is 
heavily coated and the breath intolerably fetid. The hear- 
ing is frequently blunted from extension of the disease to 
the Eustachian tubes, and abscess of the ear sometimes 
results, while nasal breathing is usually entirely abolished. 
The fever, pain, and difficulty of swallowing become greater 
and greater if an abscess is forming, and the relief is pro- 
portionately great after it has opened. As the patient ex- 
pectorates the pus he feels almost w^ell, so great is the sense 
of relief, the fever and pain subsiding together. 

Trcatuioit. — A thorough application of a solution of 
nitrate of silver, of the strength of i or 2 drams to i fluid- 
ounce of water, frequently aborts the attack if applied early 
and the inflammation is superficial. The silver solution 
should be freely painted upon the tonsils and adjacent in- 
flamed mucous membrane by means of a swab of cotton. 
The relief experienced by the patient as the result of the 
application is almost instantaneous, and the application 
should be repeated once or twice a day until all inflamma- 
tory symptoms have subsided. The nares and pharynx 
should be washed by means of a spray from an atomizer 
containing a detergent solution (Formulas i to lo) before 
making these applications, and Formula 132 or 140 maybe 
prescribed for the patient's use in the intervals between the 
applications. It is best also to open the patient's bowels 
thoroughly at the commencement of an attack by means of 
a saline cathartic. When these measures do not succeed in 
aborting the attack, but the fever and suffering of the patient 
are constantly increasing, aconite in drop doses of the tinc- 
ture every hour or two will give most excellent results. 
When pus has formed the abscess should be opened. 

The surgeon should carefully search for fluctuation by 
means of his forefinger introduced into the patient's mouth. 
As the abscess is almost always peritonsillar, a fluctuating 
area is most commonly felt through the anterior pillar above 
the tonsil. Into this place, the so-called point of election 
(Fig. 123), a small bistoury should be carefully thrust with 
the blade vertical, in order to avoid as far as possible cutting 
any large vessel that may occupy an anomalous position in 
this region. If a sudden cessation of resistance indicates 



2l8 DISEASES OF THE NOSE, THROAT, AND EAR 




that an abscess-cavity has been penetrated, the blades of a 
pair of angular scissors or forceps should be introduced 
and the puncture stretched open until the pus has escaped. 
If necessary the opening may be enlarged by cutting down- 
ward with a probe-pointed knife. The cavity may then be 
washed out with sterile water. The escape of pus is fol- 
_ lowed by immediate and great 

relief and all symptoms usually 
quickly subside. Even when no 
pus escapes from the incision, the 
bleeding affords a certain amount 
of relief and may bring about reso- 
lution of the inflammation. The 
surgeon, therefore, should not 
hesitate to puncture a hardened 
but not fluctuating mass at the 
so-called point of election, as the 
procedure is usually followed by 
satisfactory results in cases where 
no pus is encountered. 

Occasionally when the tonsils 
are adherent to the anterior or 
posterior pillars of the fauces an 
abscess will form between the tonsil and the pillar. Under 
such circumstances if a suspicious hardness is felt, either in 
front of or behind the tonsil, it should be separated from 
the pillar by means of a curved knife (Fig. 126). The 
procedure is sometimes followed by an escape of pus. 

In the case of adults the writer has in many instances 
aborted follicular tonsillitis by the following method : Each 
affected crypt was in turn washed out with peroxid of 
hydrogen, by means of a Blake's middle-ear cannula 
screwed on to a hypodermic syringe. The curved tip of 
the cannula employed is about J inch in length and 
capable of reaching to the bottom of the follicle. Only a 
drop or two of the peroxid is injected at one time, but the 
process is repeated until all of the exudate has disappeared. 
A fine Allen's probe with a few fibers of cotton wrapped 
about its end is then bent to an appropriate angle, and, after 
being dipped into a solution of nitrate of silver (i dram 



Fig. 123.^ — Phlegmonous tonsillitis. 
The black line represents the so- 
called point of election for punctur- 
ing a peritonsillar abscess. 



DISEASES OE THE TONSILS 



219 



to I ounce), is carried to the bottom of a follicle and the 
process repeated until each of the affected crypts have 
received the silver solution. The surface of the tonsil is 
then painted with the same solution. The treatment is 
followed inmiediately by a sense of relief and comfort, and 
the difficulty in swallowing is in a great measure alleviated. 
The process may be repeated two or three times a day, and 
in successful cases brings about a cure at the end of the 
second or third day. 

In cases of children or in adults, when as the result of 
timidity or excessive irritability of the fauces, this method 
is not applicable, spraying the parts with peroxid of hydro- 
gen and the application of a 60-gr. solution of nitrate of 




Fig. 125. — Posterior view of the extir- 
FiG. 124.- — Chronic folluulai tonsillitis (Frith- pated tonsil from the case illustrated in Fig. 
w.^Kl;. 124. Bristles have been introduced into the 

follicles (Friihwald). 

silver suffices for the local treatment. A 60-gr. solution of 
silver carefully applied to the tonsils occasions little or no 
discomfort in health, and when the mucous membrane of 
this region is inflamed the solution acts as a sedative and 
its application is followed by a sense of relief and comfort. 
This, however, is by no means true of the mucous mem- 
brane covering the posterior wall of the pharynx, and care 
should be exercised not to irritate it by the application of 
the silver solution. 

Chronic Inflammation of the Tonsils Without Hypertrophy. 
— The condition is characterized by a feeling of fulness 
and discomfort in the region of the tonsils. Upon inspec- 
tion, the tonsils, although not hypertrophied, are redder 
than normal, and many of the crypts are filled with a 



220 DISEASES OF THE NOSE, THROAT, AND EAR 



cheesy exudate (Figs. 124, 125). The neighboring; lymph- 
atics are usually enlarged and generally tender to the touch. 
Treatment. — The cheesy exudate should be carefully 
removed from the crypts, and a saturated solution of iodin 
applied to the interior of each crypt by means of a few 
shreds of absorbent cotton wrapped about the end ■ of a 
fine probe which is bent to a right angle. Should biweekly 
applications of iodin in this manner to the interior of the 
crypts not prove successful, a fine 
galvanocautery-knife should be in- 
serted while cold into such of the 
crypts as resist treatment, and while 
in situ sufficiently heated to destroy 
the secreting surfaces and burn 
through the tissues to the surface. 
In cases where the crypts are very 
deep, cutting through to the sur- 
face of the tonsil is a somewhat 
painful procedure, and Abraham's 
knife (Fig. 126) had better be used 
for the purpose, after which the 
wound should be seared with the 
galvanocautery to prevent its re- 
uniting during the healing process. 
Abraham's knife is also convenient 
for dissecting loose the tonsil when 
adherent to the faucial pillars. 

The cheesy secretions can readily 
be removed by directing against the 
mouth of the crypt a current of air 
from an air-compressor by means of the smallest-sized 
Eustachian catheter fitted upon the automatic cut-off (Fig. 
42). Under such circumstances the little masses are blown 
out of the crypts with considerable force, and sometimes 
strike the opposite side of the pharynx. 

Cyst of the Tonsil. — Occasionally the tonsil becomes t'nfe 
seat of cystic disease. Usually the cyst is small in size, 
but sometimes it may be of sufficient capacity to contain \ 
dram of milky fluid or the contents of the cyst may be of 
cheesy consistency. 




Fig. 126.— Abraham's tonsil 
knives. Approximately two- 
thirds actual size. 



DISEASES OE TJ/E TONSILS 221 

Treatment. — The anterior wall of the cyst should be 
excised and its interior painted with saturated tincture of 
iodin. 

Chronic Inflammation of the Tonsils With Hypertrophy. — 
There are three varieties of chronic hypertroi)hy of the 
tonsils met with in practice : First, the ordinary soft hyper- 
trophy of the tonsils found in children and young adults. 
Second, the so-called ragged tonsil, the result of frequent 
abscesses, which have caused the sloughing away of a 
portion of the glandular mass ; and, third, the scirrhous or 
hard tonsil, which is characterized by an enormous increase 
of the connective tissue of the gland and a canahculariza- 
tion of its blood-vessels. 




Goodwillie's tonsil-compressor. 



Symptoms. — There is generally more or less obstruction 
to breathing : the patient snoring during sleep. The artic- 
ulation is what is termed thick and there may be some 
difficulty in swallowing, especially in the cases of young 
children. The crypts of the tonsil may become filled with 
cheesy masses, which, undergoing putrefaction, imparts to 
the breath an offensive odor. Hypertrophied tonsils also 
sometimes interfere with the proper performance of the 
functions of the Eustachian tubes and thus are the cause 
of aural catarrh and deafness. 

Treatment. — Removal of the major portion of the hyper- 
trophied gland, either with the tonsillotome or snare or by 
means of the galvanocautery. Occasionally the operation 
with the tonsillotome is followed by dangerous hemorrhage. 
Under such circumstances Goodwillie's tonsil-compressor 
(Fig. 127) will be found convenient for temporarily con- 



222 DISEASES OF THE NOSE, THROAT, AND EAR 



V'v 



trolling the hemorrhage until, if necessary, more effective 
measures can be carried out. Care should be taken not to 
wound the anterior pillar of the fauces, as it contains a 
small artery which when wounded gives rise to troublesome 
bleeding. Therefore, when the anterior 
pillar is adherent to the tonsil it should 
be carefully separated from it by means 
of a probe and Abraham's knife. When 
from any cause it is undesirable to use 
the tonsillotome, the wire snare of Peters 
can sometimes be used to advantage. 
Scirrhous tonsils should not be removed 
with the tonsillotome, as, owing to the 
canalicularization of the blood-vessels, a 
wounded artery cannot contract, and the 
hemorrhage is usually long continued and 
may be profuse and alarming. Hence, 
hard tonsils are most safely removed by 
means of the Peters snare or the galvano- 
cautery snare. The hot wire severs the 
tonsil almost as quickly as the tonsil- 
lotome, but leaves a burned surface that 
is painful and somewhat slow to heal. 

Should an artery be observed to spurt 
after an operation upon the tonsils, the 
bleeding spot should be pierced with a 
tenaculum, by twisting which a sufficient 
amount of torsion can usually be made 
upon the tissues to stop the hemorrhage, 
or the artery can usually be seized by 
long-bladed hemostatic forceps and the 
bleeding stopped by compression or tor- 
sion. 

In cases of long-continued oozing of 
blood from the cut surface of the tonsil. 
Formula 22 may frequently be used with success to con- 
trol it, or the solid stick of nitrate of silver may be rubbed 
over the bleeding surface. 

The operation for removing the tonsils with the tonsillotome 
is performed as follows : The patient, if a child, should be 



--> 



C--^N 



[k 



Fig. 



Ermold's 



tonsillotome. 



DISEASES OE THE TONSILS 223 

seated in the lap of an assistant, who holds the child's le^^s 
between his own to prevent struggling. The assistant then 
passes his arms under the child's arms and grasps the 
child's forehead with his two hands in such a manner as to 
control the movements of the child's head. When the 
assistant elevates his elbows the child's arms are extended 
in such a manner as to prevent the child reaching his face 
with his hands and interfering with the operation. 

The tonsillotome is introduced into the child's mouth flat- 
wise, like a tongue-depressor, and serves to hold down the 
root of the tongue and afford a good view of the lower 
border of the tonsil. The ring of the tonsillotome is now 
passed around the tonsil from below in order to be sure 
that the lower border of the tonsil is encircled by the ring, 
which is pressed firmly against the wall of the pharynx. 
The blades of the instrument are now closed and tonsillo- 
tome and tonsil removed together from the mouth. If the 
operator is provided with two tonsillotomes it is generally 
feasible to remove the second tonsil before releasing the 
child, unless bleeding is excessive to a degree to interfere 
with a view of the fauces. 

The operator should be provided with a set of at least 
three tonsillotomes, in order that he may select one with a 
ring of just sufficient size to snugly fit around the tonsil to 
be removed. After encircling the tonsil the instrument 
should be closed somewhat deliberately, and the operator 
should be careful to make no effort to remove the tonsillo- 
tome from the mouth until the tonsil has been completely 
severed. It should be borne in mind that the tonsils are 
not very sensitive. Indeed, they can be touched with the 
red-hot cautery-knife without causing much pain. The 
operation, therefore, is not especially painful, and probably 
causes less discomfort to the patient than the administration 
of ether, which, of course, if used adds an increased risk to 
the operation. However, there is no great objection to 
administering ether for tonsillotomy. Under such circum- 
stances the tonsils are removed with the child's head turned 
to one side and hanging over the end of the table, to 
prevent as far as possible the flow of blood into the 
larynx. 



224 DISEASES OF THE NOSE, THROAT, AND EAR 




The operation with the galvanocautcry is performed in 
the following manner : A small galvanocautery-knife is 
introduced (cold) into one of the crypts of the tonsils and, 
being heated while in situ, is made to 
burn its way out. Two or three such 
burns may be made at a sitting upon 
a tonsil, and will be followed by con- 
siderable shrinking of the hypertrophied 
gland. But one of the tonsils should 
be operated upon with the galvano- 
cautcry at any one time, and from five 
to fifteen such operations are required 
to reduce the gland to satisfactory di- 
mensions. 

When it is necessary to operate 
under ether, the tonsils can sometimes 
be removed with less hemorrhage by means of a snare 
than by the tonsillotome. For this purpose Peters' ton- 
sil snare is the most useful instrument; as by means 
of the powerful leverage afforded by this instrument the 
wire severs the tonsil almost as rapidly as the knife of a 




Fig. 129. — Myles' tons 
punches. 




Fig. 130. — Reflex spasm of the glottis, caused by a large hypertrophy of the lingual tonsil 

(Rice). 



tonsillotome. The wire loop is made to encircle the tonsil, 
which is then drawn out of the space between the pillars by 
means of Kirkpatrick's tonsil tenaculum forceps. The 
wire loop is pressed firmly against the pharyngeal wall as 



DISEASES OE THE UVULA 



225 



the tonsil is pulled out through it by the forceps, and finally 
encircles the base of the tonsil so that as the loop is tjf^ht- 
ened the tonsil is comi)letely enucleated from its bed. 
Hemorrhage is controlled by packing a strip of iodoform 
gauze into the space between the anterior and posterior 
pillars from which the tonsil was removed. 

Sometimes in the case of bleeders and others it is desir- 
able to remove the tonsil piecemeal. P'or this purpose one 
of the so-called tonsil punches (Fig. 129) may be used. 




Fig. 131. — Kirkpatrick's lingual tonsil scissors. 

Hypertrophy of the Lingual Tonsil. — Occasionally the mass 
of adenoid tissue at the base of the tongue becomes suffi- 
ciently hypertrophied (Fig. 130) to cause a reflex cough. 
Under such circumstances the redundant tissue may be cut 
away by means of Kirkpatrick's scissors (Fig. 131). The 
serrated edges of the instrument do not allow the flabby 
tissues to slip, while the curve of the blades is such as to 
fit the base of the tongue. 



DISEASES OF THE UVULA 

Inflammation of the uvula may occur primarily or as the 
result of extension of inflammation from the tonsils or 
palate. Occasionally it becomes edematous. The disten- 
tion may be so great as to produce dyspnea. The treat- 

15 



226 DISEASES OE THE NOSE, THROAT, AND EAR 

ment consists in cocainizing the uvula, seizing it with a pair 
of mouse-tooth forceps, and freely incising the mucous 
membrane in a number of places in order to allow the fluid 
to escape. The same object may be accomplished some- 
times more conveniently by snipping off the mucous mem- 
brane at the tip of the uvula. 

Pseudo7nembranoiis Uvtt litis. — The extension of a pseudo- 
membrane from the tonsils to the uvula is somewhat 
characteristic of diphtheria. However, this occurs in other 
forms of pseudomembranous pharyngitis. 

Treatjnent of Inflammation of the Uvula. — As inflamma- 
tion of the uvula generally is only part of an inflammation 
involving the rest of the fauces, it is best to begin treatment 
by spraying the fauces with a i : lOOO solution of adrenalin ; 
the uvula should then be painted with a lo per cent, solu- 
tion of nitrate of silver. This should be done in the 
physician's office once or twice a day, the patient in the 
intervals either spraying his fauces every two or three hours 
with a I : 10,000 solution of adrenalin or a 3 per cent, 
solution of alumnol. 

Ulceration of the Uvula. — The uvula sometimes becomes 
ulcerated as the result of traumatism and infection. Syph- 
ilis, lupus, or tuberculosis may be primarily located in the 
uvula. The uvula is sometimes destroyed by an ulcerating 
gumma. Occasionally these cases are first seen by the 
laryngologist when the ulcer has made considerable prog- 
ress and the uvula hangs, as it were, by a string of mucous 
membrane. Under these circumstances the uvula some- 
times can be saved by the daily subcutaneous injection of 
bichlorid of mercury (Formula 'jG), which, although painful, 
probably yields quicker results than other methods of treat- 
ment. Where an increasing gumma involves the posterior 
wall of the pharynx as well as the uvula and soft palate, 
there is great danger of cicatricial adhesions occurring that 
may entirely shut off communication between the posterior 
naris and oropharynx. 

Deformities of the Uvula. — Bifid Uvula. — The uvula when 
present is always bifid in cleft palate as the result of the 
same cause that produces the palate deformity. Hence, 
ordinary bifid uvula might be considered as an incomplete 



DISEASES OE 77 IE UVULA , 22/ 

cleft palate. The deformity varies from a little dent at the 
free extremity of the uvula, which is usually club shaped, 
to a complete division separating the uvula into two 
lateral halves. 

Trcatjncnt. — Bifid uvula, when it causes no symptoms, 
is best let alone. However, the parts may be freshened by 
means of a V-shaped incision and sewed together. If the 
uvula is thoroughly cocainized and then sprayed with 
adrenalin the operation is both painless and bloodless. For 
anesthetizing the uvula simply painting the parts with a lo 
})er cent, solution of cocain is not sufficient. The operator 
should be provided with a small cup at the end of a long 
handle. This is partly filled with a 4 per cent, solution of 
cocain and held under the palate in such a manner that the 
uvula soaks in the cocain solution for a few moments before 
the operation. 

Elongation of the Uvula. — The whole mass of the uvula 
may be hypertrophied. More frequently, however, merely 
the mucous membrane is relaxed and hangs as a conic tip 
below the uvula proper. In rare cases a warty growth is 
attached to the end of the elongated uvula. 

Etiology. — It is generally the result of chronic pharyn- 
gitis, the constant hawking to dislodge masses of mucus 
from the pharynx having a tendency to cause the affection. 
Paralysis of the palate is a reflex sometimes observed in 
cthmoiditis, and in such cases paralysis of the azygos 
uvulae muscles and consequent elongation of the uvula are 
concomitant with the affection. 

Symptoms. — Patients complain of ** a tickling in their 
throats." The elongated uvula hanging in contact wath the 
base of the tongue causes an almost constant short cough 
as an effort to dislodge a supposed foreign substance. 
These efforts are sometimes persisted in until nausea and 
vomiting result. Snoring is usually marked and the sleep 
is disturbed by dreams. 

Trcatmoit. — The redundant portion of the uvula should 
be amputated. This is ordinarily only relaxed and re- 
dundant mucous membrane at the tip of the uvula. It is 
rarely or never necessary to remove any of the muscular 
structure of the organ, and amputation of the entire uvula 



228 DISEASES OF THE NOSE, THROAT, AND EAR 

close up to the soft palate is done only for the removal of 
malignant disease or as the result of the ignorance or awk- 
wardness of the operator. The operation is perhaps best 
done in the following manner : The uvula is grasped at a 
point just below where it is decided to amputate with a 
pair of long hemostats, which are then clamped. The 
position of the hemostat marks the spot on the uvula where 
it has been decided to amputate ; so that there is no danger 
of cutting off too much or too little. The uvula is stretched 
well forward and cut off close to the forceps by a single 
cut of a pair of somewhat heavy scissors, curved upon the 
flat, and held with their concavity upward in such a manner 
that the uvula is cut somewhat obHquely upward ; and the 
wound, being upon the posterior surface, is protected from 
contact with food during the healing process. Generally 
there is but little inflammatory reaction and the wound 
heals promptly, but occasionally a mild acute pharyngitis 
occurs as the result of the operation when the uvula is 
thick and fleshy. 



THE LARYNX 

ANATOMY OF THE LARYNX 

The larynx is an expansion of the upper portion of the 
trachea, so that there is formed a musculo-cartilaginous- 
membranous box constituting the essential organ of voice. 
It lies in front of the pharynx, of which it, with the base of 
the tongue, forms the lower anterior wall. Its superior 
aperture slopes downward and backward toward the pharynx 
and is partly closed from before backward during degluti- 
tion by a leaf-shaped lid, the epiglottis. The larynx is 
connected by ligaments and muscles with the surrounding 
tissues, the muscles serving to draw it upward during 
vocalization and deglutition. 

Cartilages. — The cartilages of the larynx are nine in 
number, three single and three in pairs : The thyroid, cri- 
coid, and epiglottic cartilages, the arytenoid cartilages, the 
cartilages of Wrisberg, and those of Santorini. The shapes 
of these, their relative size, and their manner of articulation 
and relative position to the hyoid bone is shown in Figs. 
132 and 133. 

The thyroid cartilage, so called from its resemblance in 
shape to a shield, is composed of two plates or wings, 
united in front at an angle in such a manner as to project 
forward beneath the skin of the throat as an elevation — 
the "Adam's apple." To its outer surface are attached 
the sternothyroid, thyrohyoid, and inferior constrictor 
muscles. To its inner surface are attached the epiglottis, 
the thyro-arytenoid, thyro-epiglottidean muscles, and the 
true and false vocal cords. The superior border of the 
cartilage curves backward from a median notch to the 
superior cornua or horns. To this border is attached the 
thyrohyoid membrane or ligament (Figs. 132, 133). The 
lower border gives attachment to the cricothyroid mem- 

229 



230 DISEASES OP THE NOSE, THROAT, AND EAR 



brane or ligament in the median line, and on each side to 
the cricothyroid muscles (Figs. 134, 135). The posterior 
borders and superior and inferior horns give attachment 
to the stylo- and palatopharyngeus muscles. To the apices 
of the superior cornua is attached the thyrohyoid liga- 
ment. The inferior cornua articulate with the cricoid car- 
tilage. 




Fig. 132. — Articulations and lig-aments of 
the larynx, anterior view : A, Hyoid bone, 
with a its greater, and a' its lesser cornua ; 
1-5, ligaments; 6, lateral cricothyroid artic- 
ulation ; 7, junction of cricoid and trachea. 
(Testut.) 



Fig. 133. — Articulations and ligaments of 
the larynx, posterior view: ^, Hyoid ; B, 
thyroid, with b and b' its cornua ; C, cricoid ; 
D, arytenoids ; E, cartilages of Santorini ; 
F, epiglottis ; G, trachea ; 1-6, ligaments ; 
2, opening for superior laryngeal artery ; 7, 
junction of trachea and cricoid. (Testut.) 



The cricoid cartilage, so called from its seal-ring shape, 
lies below the cricoid with its seal or broad surface pos- 
teriorly ; laterally it articulates with the inferior cornua of 
the thyroid by means of small articular facets, and on the 
superior border posteriorly are two other facets for articu- 
lation with the arytenoid cartilages. To its lateral surfaces 
are attached the crico-arytenoideus posticus muscles and 
the longitudinal fibers of the esophagus (Figs. 134, 135). 



ANATOMY OF TIIR LARYNX 



231 



To its upper border are attached the cricotliyroid nienibrane 
and the crico-arytenoidei lateralis muscles ; to its lower bor- 
der a fibrous membrane connecting it with the upper ring 
of the trachea. 




Fig. 134. — Larynx with its muscles, pos- 
terior view : I, Epiglottis ; 2. cushion; 3, 
aryepigiottic ligament ; 4, cartilage of Wris- 
berg ; 5, cartilage of Santorini ; 6. oblique 
arytenoid muscles ; 7, transverse arytenoid 
muscle; 8, posterior crico-arytenoid muscle; 
9, inferior cornu of thyroid cartilage ; 10, 
cricoid cartilage ; 11, posterior inferior cera- 
tocricoid ligament; 12, cartilaginous por- 
tion; 13, membranous portion of trachea. 
(Stoerk.) 




Fig. 135. — Larynx and its lateral muscles 
after removal of the left plate of the thyroid 
cartilage : i, Thyroid cartilage ; 2, thyro- 
epiglottic muscle; 3. cartilage of Wrisberg; 
4, aryepiglottic muscle ; 5. cartilage of San- 
torini ; 6, oblique arytenoid muscles ; 7, 
thyro-arytenoid muscle ; 8, transverse aryte- 
noid muscle ; 9, processus muscularis of 
arytenoid cartilages ; 10, lateral crico-aryte- 
noid muscle ; 11, posterior crico-arytenoid 
muscle ; 12, cricothyroid membrane ; 13, 
cricoid cartilage ; 14, attachment of crico- 
thyroid muscle ; 15, articular surface for the 
inferior cornua of the thyroid cartilage ; 16, 
cricotracheal ligament ; 17, cartilages of 
trachea ; 18, membranous part of trachea. 
(Stoerk.) 



The arytenoid, or " pitcher-shaped " cartilages, articulate 
with the upper posterior border of the cricoid (Figs. 132- 
135). To the anterior surface are attached the false vocal 
cords and thyro-arytenoideus muscles ; at the anterior angle 



232 DISEASES OE THE NOSE, THROAT, AND EAR 

or vocal process are attached the true vocal cords and the 
thyro-arytenoideus muscles. To the posterior surface is 
attached the arytenoideus muscle. To the posterior angle, 
or processus muscularis (Fig. 137), are attached the crico- 
arytenoideus lateralis and posticus muscles (Figs. 134, 135). 
The median surfaces of the arytenoid cartilages are covered 
with mucous membrane and face each other; their apices 
articulate with the cartilages of Santorini. 

Cartilages of Santoririi are two small cartilages at the 
apices of the arytenoid cartilages, to which are attached the 
aryteno-epiglottidean folds. 

Cartilages of Wrisberg are two little masses of cartilage 
contained in the arj^teno-epiglottic folds. 




Fig. 136. — Diagram to illustrate the thyro-arytenoid muscles ; the figure represents a 
transverse section of the larynx through the bases of the arytenoid cartilages : Ary, Ary- 
tenoid cartilage : /.;«. processus muscularis ; /.z', processus vocalis; 77i, thyroid carti- 
lage; f .7', vocal cords; Oe \% placed in the esophagus; vi.thy.ar.i, internal thyro-ary- 
tenoid muscle; inthy.ar.e, external thyro-arytenoid muscle; m.thy.ar.fp, -p^rt of the 
thyro-aryepiglottic muscle, cut more or less transversely; vt.ar.t, transverse arytenoid 
muscle. (Redrawn from Foster.) 

Epiglottis. — The cartilage of the epiglottis is leaf shaped and 
attached by its apex to the thyroid's inner surface just below 
the median notch by the thyro-epiglottidean Hgament 
(Figs. 132, 133). The epiglottic cartilage is covered by 
mucous membrane. Its base is free and points backward 
from the root of the tongue, to which its anterior surface is 
attached by three glosso-epiglottic folds of mucous mem- 
brane, and to the hyoid bone by the hyo-epiglottic ligament. 
The lateral margins are connected with the arytenoid carti- 
lages by the aryteno-epiglottic folds. Its posterior surface 



ANATOMY OF THE LARYNX 



233 



covers the superior aperture of the hirynx when food passes 
down the pharynx. 

Ligaments. — The hirynx has nineteen hgaments — three 
extrinsic, binding the larynx to the hyoid bone, and six- 
teen intrinsic, binding its 
various cartilages to- 
gether. 

The extrinsic ligajiients 
are the thyrohyoid mem- 
brane and two lateral liga- 
ments (Figs. 132, 133). 

The intrifisic ligaments 
are the cricothyroid mem- 
brane, the cricothyroid 
capsular ligaments (two), 
crico-arytenoid ligaments 
(two), crico-arytenoid cap- 
sular ligaments (two). In 
the false cords or ventric- 
ular bands the superior 
thyroarytenoid ligaments 
(two). In the true vocal 
cords the inferior thyro- 
arytenoid ligaments (two), 
the hyo-epiglottic liga- 
ment, the thyro-epiglottic 
ligament, and the three 
glosso-epiglottic folds. 

Muscles. — There are 
four pairs of lateral mus- 
cles and one central 
muscle, the aryteyioidcns , 
which extends from the 
posterior surface and 
outer border of one aryte- 
noid cartilage to the corresponding parts of the other. There 
are both oblique and transverse fibers, and the action of the 
muscle is to draw the arytenoids together and close the pos- 
terior portion of the chink of the glottis (Fig. 1 34). It is sup- 
plied by both the superior and recurrent laryngeal nerves. 




Fig. 

larynx 
cushion ; 



t37. — Vertical transverse section of the 
I, Posterior face of epiglottis, with i', its 
2, aryteno-epiglottic fold; 3, ventricular 
band, or false vocal cord ; 4, true vocal cord ; 5, 
central fossa of Merkel ; 6, ventricle of larj'nx, 
with 6', its ascending pouch ; 7. anterior portion 
of cricoid ; 8, section of cricoid ; 9, thyroid, cut 
surface; 10, thyrohyoid membrane; 11, thyro- 
hyoid muscle ; 12, aryteno-epiglottic muscle; 13, 
thyro-arytenoid muscle, with 13', its inner division, 
contained in the vocal cord ; 14, cricothyroid 
muscle; 15, subglottic portion of larynx; 16, 
cavity of the trachea. (After Testut.) 



234 DISEASES OF THE NOSE, THROAT, A/vD EAR 

The four pairs oi lateral muscles are : 

The crico-arytenoideus lateralis, extending from the pos- 
terior angle of the base of the arytenoid to the upper lateral 
border of the cricoid cartilage. This muscle rotates the 
arytenoid inward and, with its fellow of the opposite side, 
closes the glottis except for the posterior portion, closed 
as described above by the action of the arytenoideus, bring- 
ing the bases of the arytenoid cartilages together. The 
lateral crico-arytenoids are supplied by the recurrent laryn- 
geal nerve. 

The cricothyroid, extending from the front and side of 
the cricoid cartilage to the lower and inner border of the 
thyroid (Fig. 136), The action of this muscle is to tilt the 
thyroid forward upon the cricoid and thus stretch and 
render tense the vocal cords. It is supplied by the superior 
laryngeal nerve. 

The crico-arytenoideus posticus extends from the pos- 
terior angle of the base of the arytenoids to the posterior 
portion of the cricoid (Figs. 134, 135). Its action is to 
rotate the arytenoids outward and open the glottis while 
keeping the cords tense. It is supplied by the recurrent 
laryngeal nerve. 

The thyro-arytenoideus extends from the angle of the 
thyroid cartilage and the posterior surface of the cricothyroid 
membrane into the base and anterior surface of the arytenoid 
(Fig. 137). Its action is to shorten and relax the vocal 
cords by bringing the thyroid and arytenoids closer to- 
gether and to compress the sacculus laryngis. It is 
supplied by the recurrent laryngeal nerve. 

The action of the intrinsic muscles may be studied by 
reference to Fig. 136 and the other figures illustrating the 
anatomy of the muscles of the larynx. Briefly, the chink 
of the glottis is closed by the action of the arytenoideus 
and the crico-arytenoideus lateralis. The cords are tight- 
ened and made tense by the action of the cricothyroid. 
The cords are relaxed by the action of the thyro-arytenoid- 
eus and separated by the action of the crico-arytenoideus 
posticus. The study of the action of the muscles of the 
larynx may be also facilitated by inspecting the figures 
illustrating laryngeal paralysis (Figs. 1 54-161). 



ANATOMY OF TIIK LARYNX 235 

The muscles of the epiglottis are three double muscles, 
all supplied by the recurrent laryn<^eal nerves. Their 
action is to depress the epiglottis and compress the sacculus 
laryngis. The epiglottic muscles are the thyro-epiglottideus, 
between the inner surface of the thyroid and the epiglottis 
and aryteno-epiglottic folds ; the aryteno-epiglottideus 
superior, between the apices of the arytenoids to the aryteno- 
epiglottidean fold ; and the aryteno-epiglottideus inferior, 
from the arytenoid cartilage just above the ventricular bands 
to the sacculus laryngis. 

The vocal cords, sometimes called the true vocal cords in 
contradistinction to the false vocal cords or ventricular 
bands, extend anteroposteriorly across the larynx from the 
angle of the thyroid cartilage to the anterior angle of the 
arytenoids (Figs. 133-136). They each consist of a fold of 
mucous membrane containing the inferior thyro-arytenoideus 
ligament with the thyro-arytenoideus muscle parallel to it 

(Fig. 137)- 

The ventricular bands are two folds of mucous membrane 
containing the superior thyro-arytenoid ligament extending 
across the larynx above the ventricles of the larynx 

(Fig 137)- 

The glottis, or rima glottidis, sometimes called the chink 
of the glottis, is the space between the vocal cords. When 
the cords are separated during forced inspiration it is 
triangular in shape, with the apex of the triangle anterior. 
Its length rarely is i inch in the male, and its width 
posteriorly during inspiration does not exceed \ inch. 

The ventricles of the larynx are oval depressions between 
the ventricular bands and the cords leading upward toward 
the sacculus laryngis. 

The sacculus laryngis is the upper portion of the ventricle 
of the larynx. It contains sixty or seventy small mucous 
glands, whose secretion lubricates the cords. It is of conic 
shape and is covered by the aryepiglottideus inferior muscle 
medianly and the thyro-epiglottic muscle laterally. Both 
muscles by their action compress it and expel its contents 

(Fig. 137)- 

The mucous membrane of the larynx is somewhat thin. 
It is covered with ciliated columnar epithelium below the 



236 DISEASES OF THE NOSE, THROAT, AND EAR 

level of the ventricular bands, extending up in front as high 
as the center of the epiglottis. Over the rest of the mucous 
membrane of the larynx is stratified squamous epithelium. 

The abrupt change in the character of the epithelium of 
the larynx probably accounts for the rarity of infection of 
the pharynx extending into the lower air-passages ; as it is 
a well-established fact that infections of mucous membranes 
generally respect anatomic boundaries when the character 
of the epithelium covering suddenly changes. 

The arteries of the larynx are the laryngeal branches of 
the superior and inferior thyroid. The most important of 
these from an operative standpoint is the cricothyroid, which 
extends transversely across the cricothyroid membrane to 
anastomose with its fellow of the opposite side. This artery 
is seldom large enough to require ligation in deliberate 
operating. However, in emergency cases, where it is 
necessary to open the cricothyroid membrane as quickly as 
possible, it is better to cut the cricothyroid membrane trans- 
versely in order to avoid wounding this vessel. 

The veins empty into the superior, middle, and inferior 
thyroid veins. Ordinarily these are vessels of small size, 
but in obstructed respiration from stenosis their size is 
greatly increased. 

The nerves of the larynx are the superior and recurrent 
branches of the pneumogastric joined by branches of the 
spinal accessory and the sympathetic. The superior laryn- 
geal is mainly a nerve of sensation. It enters the larynx 
through an opening in the thyrohyoid membrane and 
supplies the mucous membrane, the cricothyroid, and ary- 
tenoideus muscles. 

The recurrent laryngeal is a motor nerve. It winds from 
before backward around the subclavian artery on the right 
side and around the arch of the aorta on the left side, and 
supplies all the laryngeal muscles except the cricothyroid. 
In its course it gives off cardiac, esophageal, tracheal, and 
pharyngeal filaments. It anastomoses with the superior 
laryngeal. 

Aneurism of the aorta or subclavian pressing on the re- 
current laryngeal nerve produces characteristic paralysis of 
the laryngeal muscles, and the same is true of hypertrophied 



ANATOMY OF TI/E LARYNX 237 

or tubercular lymphatics in the mediastinum or in the 
neck. 

The size of the larynx varies greatly, being much larger 
in males than in females and children. At the age of 
puberty in boys the voice undergoes a rapid change in 
character and pitch. During this period of change the 
mucous membrane of the larynx is usually at least some- 
what congested, and occasionally individuals are unable to 
control the pitch of their voices to the extent that they will 
begin a sentence in a high-pitched voice and end it in a bass 
voice or the reverse. 

Musical notes used in singing have a range of about 3^ 
octaves, and voices are classified according to their position 
in the musical scale into soprano, mezzosoprano, contralto, 
tenor, baritone, and bass. Soprano, mezzosoprano, and 
contralto voices are usually found in women, while the 
male voice is usually either tenor, baritone, or bass. Voice 
production is the result of the vibration of the vocal cords 
amplified by the resonant cavities above ; that is, the 
pharynx, the mouth, the nose ; in the same manner that the 
sound of a tuning-fork is amplified and made many times 
louder by approaching the vibrating fork toward the open- 
ing in a wide-mouthed bottle of a sufficient depth to con- 
tain a column of air capable of vibration in unison with 
the fork. The sound produced by the vibrations of the 
vocal cords is feeble and practically inaudible until it is 
amplified and made loud by the vibration of the air in the 
mouth, pharynx, and nose. The size of this cavity can be 
greatly reduced by the contraction of the palate, shutting 
off the cavity of the nose and nasopharynx from the space 
below, and the size and shape of the cavity of the mouth 
and oropharynx can be changed by the action of the 
muscles of the tongue and pharynx ; so that it is possible 
to produce a space containing a volume of air capable of 
vibrating in unison with and amplifying a sound of any 
pitch produced by the vibration of the vocal cords. The 
larynx possesses the characteristics of both reed and string 
musical instruments. The pitch of a sound produced by 
the vibration of the vocal cords depends upon their length, 
thickness, and tension. What is called the falsetto voice is 



238 DISEASES OF THE NOSE, THROAT, AND EAR 

the result of the cords vibrating not as a whole, but in two 
or more segments. The resulting sound is high pitched, 
far above the natural range of the individual's voice, and 
possessing a timbre or character usually disagreeable. Voices 
differ greatly in range, that is, some individuals have no 
more than a few notes of the musical scale, while others 
have 2 and even 2\ octaves at their command, and above 
the natural range of their voices a falsetto voice, also of 
considerable range. 

Musical notes (see p. 237) have three qualities — loudness, 
pitch, and timbre or character. We have already learned 
how loudness of voice is the result of the amplification of 
the sound produced by the resonant cavities of the mouth, 
pharynx, and nose. The loudness also is dependent on 
the force and amplitude of the vibrations of the vocal 
cords. 

The timbre or character of the voice is as varied as the 
dispositions of individuals. It is that quality by which we 
recognize the voice of an individual as different from all 
other individuals. In singers the timbre of the voice may 
be sweet and pleasant or rough, coarse, and unpleasant. 
It may be nasal, from the presence of adenoids or other 
growths that render the use of the nose as a resonant 
cavity impossible. Timbre of the voice is probably the 
result of the relative size and shape of the resonant cavities, 
the position of the teeth and lips, and the thousand and one 
anatomic peculiarities of an individual's vocal organs. In 
this connection it is Avell enough to insert a word of caution 
as to the impropriety of suddenly greatly altering the size 
or shape of the upper respiratory tract, as, for example, by 
the ablation of very greatly hypertrophied tonsils in the 
case of professional singers, for fear that the character of 
their voice may be changed for the worse rather than the 
better. 

The singing voice differs from the speaking voice mainly 
that in singing the tone is sustained at the same pitch for 
an appreciable length of time, while in speaking the voice 
is continually sliding up and down the musical scale on the 
vowel sounds. 



DISEASES OF THE LARYNX 239 



DISEASES OF THE LARYNX 

Anemia. — The presence of laryngeal anemia is of especial 
importance: (i) When associated with functional aphonia. 
(2) When, during the course of an attack of chronic laryn- 
gitis, the mucous membrane covering the aryepiglottic folds, 
arytenoid cartilages, and ventricular bands is abnormally 
pale while the vocal cords are the seat of indolent conges- 
tion, the patient not being generally anemic. Each of the 
above conditions are premonitory of laryngeal phthisis. 

Hyperemia of the larynx is a congestion of the mucous 
membrane of the larynx, most marked where the submucosa 
is loose, fat, and thick, as upon the aryepiglottic folds, ventric- 
ular bands, and ventricles ; the epiglottis, vocal cords, and 
inferior cavity of the larynx being but little altered in color. 
Its presence renders an individual more prone to contract 
acute or chronic laryngitis. 

Etiology. — Hyperemia of the larynx is oftenest the result 
of excessive smoking, especially of cigarette smoking. It 
also results from working in dusty rooms and amid irritat- 
ing chemic fumes. 

Acute laryngitis is an acute inflammation of the mucous 
membrane of the larynx, sometimes extending to the sub- 
mucous tissue and muscles. 

Synonyms. — Acute mucous laryngitis ; acute catarrhal 
laryngitis. 

Etiology. — Acute laryngitis is generally the result of ex- 
posure to wet and cold, the same causes that produce an 
ordinary coryza, acute laryngitis being in many instances 
simply an extension of the disease downward. Many in- 
dividuals have an hereditary or acquired tendency toward 
laryngeal inflammations. The affection also occurs as a 
complication in measles, variola, scarlatina, typhoid, rotheln, 
and chicken-pox, and also as the result of traumatism, such 
as the inhalation of steam or irritating vapors. When acute 
laryngitis results from traumatism, the inflammation fre- 
quently assumes the edematous form of the disease, as the 
result of the submucous tissues being involved, while in 
children the croupous form is frequently met with, the 



240 DISEASES OF THE NOSE, THROAT, AND EAR 

mucous membrane of the larynx being covered with false 
membrane. 

Symptoms. — The voice is altered in almost all cases, 'be- 
coming in some almost aphonic, and its use extremely 
fatiguing and sometimes painful. In adults the respiration 
is generally unembarrassed, embarrassed respiration indicat- 
ing that the inflammation is assuming the more serious 
character of edema. In children, on the contrary, em- 
barrassed respiration is often the first symptom of the attack, 
the embarrassed respiration quickly assuming the spasmodic 
character of croup. The expectoration in adults is at first 
clear, frothy, mucopurulent, but somewhat scanty, abundant 
expectoration indicating that the disease has extended to 
the bronchi. Expectoration in children being always very 
scanty probably explains why the paroxysms of dyspnea 





Fig. 138. — Laryngitis involving chiefly Fig. 139. — Swelling below the vocal 

the false cords as the cause of false cords from laryngitis hypoglottica 

croup (Friihwald). chronica (after Ziemssen). 

are so severe and prolonged, the pain, tickling, and sense of 
tightness in the throat being in them more severe. The 
color of the mucous membrane of the larynx as seen in the 
laryngoscope is always heightened, but varies in different 
parts of the larynx and according to the degree of the in- 
flammation, the cords in slight attacks being quite white, 
while in severe attacks they are so red as to be scarcely 
distinguished from the surrounding parts. The ventricular 
bands are also sometimes so swollen as to entirely cover 
the vocal cords or the cords may be prevented from 
approximation by swelling of the posterior glottic com- 
missure. 

Treatmejtt. — It is well to begin with the administration of 
a saline cathartic. The patient should remain in a warm 
room, avoid using his voice, and draw into his larynx every 



DISEASES OF 77/ E LARYXX 24 1 

two hours the spray from an atomizer containing a i : 10,000 
solution of adrenalin. This is readily done by the patient 
inserting the nozzle of an atomizer in his mouth and inhaling 
deeply as he presses the bulb of the atomizer. The patient 
will feel the spray enter his larynx and should continue the 
use of the atomizer until the laryngeal rriucous membrane 
is well covered by the spray. An application should be 
made to the interior of the larynx once or twice each day of 
a sedative and slightly astringent powder (Formula 59) by 
means of a powder-blower (Fig. 45). In making such an 
application to the interior of the larynx the patient is re- 
quested to grasp the tip of his tongue with a napkin and 
hold the tongue well forward. The operator, holding the 
laryngeal mirror in his left hand, introduces the mirror into 
the fauces in such a manner that he sees the reflected image 
of the glottis. The powder-blower should be held in the 
operator's right hand, and its nozzle is placed in the 
pharynx in such a position that it is seen reflected in the 
laryngeal mirror, and moved until it is observed to point 
toward the glottis. The patient is requested to say " a," 
and at the same instant the powder should be blown from 
the powder-blower into the larynx. When an individual 
says "a" or, indeed, makes any other sound with his 
vocal organs, the cords are brought together in order to 
produce it, so that any application made at that instant is 
limited to that part of the larynx above the cords. Should 
it be deemed necessary to apply the powder to the larynx 
below the cords, it may be accomplished by using the 
powder-blower while the patient holds his breath, or the 
powder may be carried deep into the bronchi if the powder- 
blower be used while the patient is inspiring. After the 
more acute stage of the disease has passed, Formula 57 or 
even 56 sliould be used instead of Formula 59 as an applica- 
tion to the interior of the larynx. In the more severe cases 
powders of any kind are not well borne, and under such 
circumstances sprays of cocain, adrenalin, and menthol- 
camphor-albolene should be employed. 

The application of cold or heat to the skin over the laiynx 
gives decided relief in the more severe cases. As to the 
selection of heat or cold the sensations of the patient would 

16 



242 DISEASES OF THE NOSE, THROAT, AND EAR 

seem to be the best guide. In the writer's experience heat 
is usually the more grateful. Cold may be applied by means 
of a Leiter coil, a small ice-bag, or a napkin wrung out of 
ice-water and applied to the neck over the larynx. It should 
be changed sufficiently often to maintain the degree of cold 
desired. 

Heat may be utilized by applying a Leiter coil upon the 
skin over the larynx in the usual manner and allowing hot 
water to flow through the coil. A folded napkin should be 
placed under the coil to protect the skin, and the tempera- 
ture of the water should be as high as can be borne com- 
fortably by the patient. 

The more severe forms of acute laryngitis, fortunately 
rare, will require careful watching, and the physician should 
be prepared to prevent suffocation from edema by scarifying 
the epiglottis or, if necessary, by intubation or tracheotomy. 

Subacute laryngitis is an inflammation of the mucous mem- 
brane of the larynx subacute in character. 

Etiology. — Subacute laryngitis commonly results from the 
same causes as the acute form of the disease. It generally 
attacks individuals of feeble constitution or it may result 
from neglecting to treat properly the acute affection. 
Usually slight dyspnea and hoarseness are prominent symp- 
toms. The former, generally worse at night, sometimes 
occasions the patient alarm. Feeble individuals, especially 
children who spend most of their lives indoors, are more 
liable to attacks of this disease than the robust and those 
who are much outdoors. A frequent predisposing cause 
is the admixture of the products of combustion with the 
hot air supplied from furnaces. A careful supervision of the 
workman each fall when the furnace is put in order for the 
winter, to make sure that the parts of the fire-box are fitted 
too tightly to allow of any escape of carbon-dioxid gas into 
the hot-air chamber, will sometimes prevent every member 
of the household suffering from recurrent attacks of sore 
throat during the entire winter. 

Dusty occupations and the frequent inhalation of irritat- 
ing fumes produce chronic laryngitis and acute exacerbations 
of the inflammation. By far the most common cause is 
exposure to cold. However, it is not usually normal res- 



DISEASES OF THE LARYNX 243 

piration of cold air that is responsible for attacks of acute 
laryngitis, because as long as the nose is normal the air in- 
spired through it is moistened and its temperature raised 
sufficiently to render it harmless to the larynx. This is not 
the case in individuals whose noses are sufficiently abnormal 
to necessitate mouth-breathing, and it is somewhat curious 
to note in this connection that during the first few years of 
a chronic nasal catarrh each cold is essentially nasal ; but in 
the later stages of the disease the brunt of such attacks is 
borne by the larynx and trachea. This is probably not due 
to an extension of the catarrhal disease by continuity of sur- 
face, but to increasing hypertrophy of the turbinated bodies, 
rendering the individual a mouth-breather as soon as he 
inhales cold air. It is not the inspiration of cold air that 
always is responsible for an attack of acute laryngitis. Most 
individuals take cold through their feet. The ground is a 
better conductor of heat than the atmosphere and therefore 
the soles of the shoes should be of heavy material. The 
shoes should be loose about the ankles so as not to impede 
the circulation, and so constructed as not to prevent the 
evaporation of moisture. A dentist friend and patient in- 
formed me that he suffered for years with cold feet until he 
adopted the plan of wearing low shoes the entire year. 
During the winter his woolen underdrawers were made long 
enough to extend over the ankles and protect them. He 
wore cotton or light wool stockings. 

Treatment. — The treatment is similar to that of acute 
laryngitis. A most important part of the treatment of acute 
laryngitis is rest, especially of the inflamed larynx. All 
unnecessary talking should be avoided and no effort made 
to talk above a whisper. In the case of singers, orators, and 
actors, where it is of the utmost importance that a normal 
voice should be regained as speedily as possible, absolute 
rest in bed in a warm room will do much to hasten the 
desired result ; \ gr. of calomel with 5 gr. of bicarbonate of 
sodium should be given every hour until six doses have been 
taken or the bowels freely moved. If the attack is of suffi- 
cient severity to cause some elevation of temperature and a 
hot, dry skin, i-drop doses of tincture of aconite root should 
be given every fifteen minutes until three or four doses have 



244 DISEASES OF THE NOSE, THROAT, AND EAR 

been taken, and then every hour until the skin has become 
moist. Of the other internal remedies, yerba santa usually 
yields the most speedy and satisfactory results, especially 
in cases unaccompanied by fever and a hot, dry skin. A 
pill containing i or 2 gr. of the extract combined with yl^- 
gr. of strychnin should be given every two hours, or the 
patient may take half a teaspoonful of malto-yerbine every 
one or two hours. The patient should inhale the spray 
from an atomizer containing a i : 10,000 solution of adre- 
naHn every one or two hours. 

Both cocain and antipyrin have sedative and astringent 
effects upon the inflamed mucous membrane of the larynx. 
The application of the former gives relief for only half an 
hour, and is followed by increased congestion. The effect 
of cocain can be maintained by frequent instillation of the 
drug or by following its use by a spray of antipyrin, which 
will maintain the local sedative effects of the cocain in many 
instances for from two to four hours. 

After the more acute stages of the disease have passed, 
and in the milder attacks of hoarseness affecting singers, 
astringents yield better results than adrenaHn, and the spray 
from an atomizer containing a 2 to 4 per cent, solution of 
alumnol may be inhaled by the patient every hour or two 
with decided advantage. In singers and actors with slight 
laryngitis the neurotic element plays an important part, and 
voice-failure when on the stage is largely due to nervous- 
ness and fear. Under such circumstances a pill containing 
2^ gr. of strychnin or a teaspoonful of the fluidextract of 
coca in a glass of sherry wine, taken immediately before the 
curtain rises, will do much to secure a satisfactory control 
of the voice during the performance. 

Chronic laryngitis is a chronic inflammation of the mucous 
membrane of the larynx. 

Etiology. — It is generally the result of faulty use of the 
voice by singers or public speakers, and also of excessive 
smoking, especially cigarette smoking. The smoking of 
cigarettes is particularly injurious, not on account of the 
paper wrappers or any peculiarity of tobacco, but from the 
habit all cigarette smokers soon acquire of inhaling the 
smoke and bringing it directly into contact with- the sensitive 



DISEASES OE THE LARYXX 245 

mucous membrane of the larynx. It is the very "mildness" 
of the smoke from cigarettes, in comparison with cigar smoke 
or tliat of a pipe, that makes them more injurious. The 
convenience and cheapness of cigarettes also causes the 
cigarette smoker to light a cigarette whenever he has a few 
moments to spare and under circumstances when he would 
not think of smoking a cigar or a pipe, the ill effects of which 
are generally confined to the pharynx. Dusty occupations 
and the frequent drinking of undiluted distilled liquors are also 
causes of the disease, while the affection is sometimes simply 
the expression of the rheumatic diathesis. The presence of 
tumors inside the larynx usually are the result rather than 
the cause of chronic laryngitis. 

Symptoms. — The voice, as a rule, is chronically hoarse, 
but the degree of hoarseness varies materially from time to 
time. In singers the injury to the voice \\\\\ be manifested 
in loss of range, diminished endurance, and loss of control. 
As the disease advances all vocal efforts will be obviously 
strained and labored. Cough is by no means a constant 
symptom. The secretion is at no time very great in amount 
and diminishes as the disease advances. It is thick, starch- 
like, and tenacious. Small amounts of mucus frequently 
collect in the interarytenoid space and, being suddenly 
detached by coughing, are thrown out through the mouth 
to a considerable distance, while little bridges of mucus are 
sometimes seen with the laryngoscope extending from cord 
to cord in the larynx. There is a constant feeling of con- 
striction, as of a foreign body in the air-passages. Upon 
inspection certain portions of the mucous membrane of the 
larynx appear redder than normal ; and sometimes the 
entire mucous membrane of the larynx is of a uniform red 
color, w^ith the exception of the cords, which may be some- 
what lighter in color than the surrounding parts. The 
mobility of the cords is frequently impaired, either from 
swelling of the mucous membrane covering the arytenoids or 
from slight muscular pain. Erosion of the interarytenoid 
space is frequently seen. 

Prognosis. — Recovery from chronic laryngitis is always 
slow, and depends upon the faithfulness with which the 
treatment is carried out. 



246 DISEASES OF THE NOSE, THROAT, AND EAR 

Treatment, — Constitutional remedies, except in rheumatism 
of the larynx, are not of the greatest importance ; but, as 
in every other chronic affection, the general health should 
be improved as much as possible. Local treatment should 
consist of the application by the patient several times a day 
to the affected mucous membrane of a sedative or astringent 
solution by means of the spray of an atomizer, a 4 per cent, 
solution of alumnol being especially useful for this purpose. 

As an office treatment applications of argyrol (10 per 
cent.) twice a week sometimes yield excellent results, and 
the occasional application of nitrate of silver solution in 
obstinate cases is very beneficial. The use of the remedy 
requires some care, and a very little of the solution should 
be used until it is ascertained that its use is not followed by 
spasm of the glottis. Most larynxes will stand the applica- 
tion of a cotton-tipped applicator dripping with a solution 
of silver nitrate (10 gr. to i ounce), and solutions of i dram 
to I ounce can cautiously be employed. The unusually 
slight irritation produced by the appHcation of even the 
stronger solutions sometimes lasts for several hours, but is 
followed by decided relief of hoarseness and congestion of 
the parts. 

In the more severe cases pain, congestion, and hoarse- 
ness are sometimes quickly relieved by the insufflation of 
powdered orthoform or antipyrin. A milder astringent 
powder consists of i part alumnol and 2 parts milk-sugar. 
It may be used with good effect in all cases of chronic 
laryngeal congestion. Sulphate of zinc (from 15 gr. to i 
ounce of milk-sugar up to equal parts of sulphate of zinc 
and milk-sugar) yields good results in some cases. 

Laryngitis Sicca. — In rare cases catarrh of the larynx 
results in an exhaustion of the fluid elements of the laryn- 
geal secretion as the result of atrophy of the glandular 
elements of the mucous membrane. The disease is 
generally associated with atrophic rhinitis and pharyngitis. 

Pathology. — The appearance of the laryngeal mucous 
membrane is similar to that of the nose and pharynx in 
atrophic rhinitis and pharyngitis. In some cases the parts 
are simply dry and glazed, looking as if varnished ; in 
other cases there are accumulations of inspissated mucus, 



DISEASES OE THE LARYNX 247 

often greenish in color and emitting an offensive odor 
similar to that observed in atrophic rhinitis. The gross 
structural alterations that are seen in the nose in atrophic 
rhinitis are not observed in atrophic laryngitis. It is a 
disease characterized by diminished and perverted secretions 
rather than by atrophy of mucous membrane, submucous 
structures, and laryngeal cartilage. The masses of inspis- 
sated secretions cling to portions of the larynx where the 
glands are most numerous — the subglottic region and the 
upper surface of the ventricular bands. 

SyinptoDis. — In cases where there are no accumulations 
the larynx feels dry and irritated. The voice is slightly 
hoarse and tires upon the slightest exertion. In cases charac- 
terized by accumulation of fetid secretions the sufferings of 
the patient are mainly due to the irritation produced by the 
presence of these secretions and by the effort to rid himself 
of them. His strength is exhausted by ceaseless and use- 
less coughing, usually worse at night. Occasionally a little 
mass will be ejected from the larynx with considerable vio- 
lence, bringing with it a small area of laryngeal epithelium, 
and producing a slight capillary hemorrhage which alarms 
the patient. In the few cases which the writer has seen — 
for the disease is somewhat rare — the patients were fairly 
well nourished. 

Trcatvicnt. — In cases where the disease is the result of 
atrophic rhinitis, efforts should be directed toward improving 
the condition of the nose, so that the important function of 
warming and moistening the inspired air is restored. The 
wearing of cyhnders of absorbent cotton within the nose, 
as directed for the treatment of atrophic rhinitis, is also 
valuable in bringing about an improved condition of the 
laryngeal secretions. 

Patients with atrophic rhinitis do well in a moist climate. 
In one case all laryngeal symptoms had disappeared upon 
the return of a patient to Philadelphia after a year's absence 
in the Philippines. Internally may be given stimulating 
expectorants or drugs, such as iodid of potassium and 
hydriodic acid, that increase the secretions of the upper 
respiratory tract and render them more fluid. 

Inhalations of steam or the use of the bottle-inhaler with 



248 DISEASES OF THE NOSE, THROAT, AND EAR 

hot water and tincture of benzoin aid greatly the patient's 
efforts to get rid of the annoying laryngeal accumulations. 
Great relief sometimes follows spraying the larynx with 
equal parts of hydrogen dioxid and Dobell's solution, 
because the action of the dioxid upon the accumulations 
softens them and increases their bulk, and hence aids their 
expulsion from the larynx. The irritation of the larynx is 
best controlled by spraying the parts with a 2 per cent, 
solution of antipyrin. 

Inflammation of tlie Submucous Tissue of the Larynx. — 
Acute edema of the larynx usually is the result of phleg- 
monous inflammation with infiltration of the surrounding 
submucous tissue, frequently endangering life by occlusion 
of the rim a glottis. 

Synonyms. — Edematous laryngitis ; phlegmonous laryn- 
gi*js ; acute edema of the larynx ; edema of the glottis. 




Fig. 140. — Phlegmonous laryngitis, with phthisic ulcer: a, Epiglottis; b, left aryepi- 
glottic fold ; c^ left pyriform sinus. (From v. Ziemssen, after Tiirck.) 

Etiology. — Edema of the glottis may result from trauma- 
tism, such as the swallowing of corrosive liquids. It occurs 
rarely as a primary affection, resulting from exposure to 
cold and wet in persons of debilitated constitution. In 
most instances, however, the disease is secondary, and re- 
sults from syphilitic or tuberculous perichondritis (Fig. 140), 
retropharyngeal abscess, Bright's disease, glycosuria, etc. 

Pathology. — The infiltration consists essentially of a 
serous or seropurulent fluid, most abundant beneath the 
mucous membrane of the aryepiglottic folds, the ventricular 
bands, and the ventricles. The submucous tissue is most 
abundant in these regions of the larynx, but the edema is 
not always limited to that part of the larynx above the 
vocal cords, but may extend to the submucosa beneath the 



DISEASES OF 77 /h L.IA'VjVX 249 

vocal cords. liifra^^Iottic edema, as the disease is tlicn 
called, is almost invariably secondary in. its ori<^in and 
always serous in character (Fig. 139). 

Symptoms. — In some cases there are no symptoms what- 
ever prior to a fatal suffocation or syncope. The voice is 
usually rou^h and deep or altogether lost, due to thicken- 
ing and heaviness of the cords. In the early stages of an 
attack the chief difficulty in breathing is during inspiration, 
but, as the disease advances, expiratory distress occurs, with 
the result of producing complete apnea. A short cough 
is present and deglutition is both difficult and painful. 
When the edema is considerable the sense of suffocation is 
most oppressive. With the laryngoscope edema is quickly 
recognized ; the infiltrated portion of the larynx being 
greatly swollen and semitransparent in appearance. When 
the edema is subglottic, the swollen mucous membrane of 
that region will almost always be seen of a more intense red 
than the cords above. 

Prognosis. — Recovery from severe primary edema is 
always doubtful, and the prognosis in secondary edema 
depends upon the circumstances of the primary cause of 
the disease. The patient can hardly be said to be out of 
danger under two or three weeks from the commencement 
of an attack, and may even then become the subject of 
chronic infiltration. When death occurs it is almost always 
the result of carbonic-acid-poisoning, and may be the direct 
effect of stenosis or spasm of the glottis. Another danger 
is the possible occurrence of suppuration — abscess of the 
larynx. 

Treatment. — Free diaphoresis should be produced in 
suitable cases by the hypodermic use of -^^ to \ gr. of 
pilocarpin. The temperature of the room in which the 
patient lies should be carefully regulated, and cold, dry 
applications kept upon the throat over the- larynx. As 
soon as edema is seen within the larynx local scarifi- 
cation with the laryngeal lancet (Fig. 141) should be 
performed. If, in spite of scarification and the use of pilo- 
carpin, edema continues with increasing respiratory distress, 
general enfeeblement, and symptoms of carbonic-acid- 
poisoning, intubation or tracheotomy should be performed 



250 DISEASES OF THE NOSE, THROAT, AND EAR 



at once. Many lives probably have been sacrificed by 
hesitation and delay. 

Laryngitis syphilitica is an inflammation of the larynx 
due to syphilis. 

Synonyms. — Specific laryngitis ; laryngeal syphilis ; syph- 
ilis of the larynx. 

Etiology. — Syphilis of the larynx most frequently occurs 
as a manifestation of the tertiary period, three to thirty years 
after the primary infection. As a 
manifestation of secondary syphiHs 
laryngeal symptoms may occur with- 
in a few weeks or may not appear 
until two or three years after syphiHs 
has been contracted. 

PatJiology. — In secondary syphilis 
the laryngeal symptoms may consist 
of a mere hyperemia, giving rise to 
the symptoms of simple laryngitis. 
Ulcerations may also be present and 
are usually symmetric, that is, if an 
ulcer is present upon one part of 
the larynx, there is usually a similar 
ulcer also upon the corresponding 
part of the opposite side of the 
larynx. Syphilitic warts or con- 
dylomata are also frequently found 
in the larynx during the secondary 
stage of syphilis. They may under- 
go ulceration or disappear sponta- 
neously. Tertiary manifestation con- 
sists of gumma, which may break 
down and cause deep ulcerations, 
with perichondrosis and necrosis of 
the cartilages ; while stenosis may 
result from cicatricial contraction 
after the healing of syphilitic ulcers. 
Symptoms. — The patient usually 
first complains of a slight hacking cough, hoarseness, and 
sometimes difficult and painful deglutition. Inspection with 
the laryngoscope reveals some of the lesions already specified. 




[41. — Tobold's laryngeal 
lancet. 



DISEASES OE THE LARYNX 



251 



Treat If lent. — ConstitutioiKil remedies already mentioned 
(see Syphilitic Rhinitis) should be employed. Alumnol or 
some other astringent should be prescribed for the patient's 

use at home, in the same manner 
as for simj)le laryngitis, while an 
application of Formula 58 should 
be made to the interior of the 
larynx every other day with the 
powder-blower. If shallow ulcers 
are present they should be touched 
each day with the solid nitrate of 
silver melted on the end of a probe. 
This may be accomplished by melt- 
ing a few crystals of the nitrate 
on a silver coin and dipping the 
end of a cold silver probe into it. 
Enough of the silver nitrate will 
adhere to the end of the probe 
to make one application. If, how- 
ever, the ulcers are deep, such ap- 
plications will not be sufficient to 
secure a speedy healing of the 
ulcers. They should then be 
touched by means of the cotton 
applicator every other day with 





Fig. 142. — Browne's hollow laryn- 
geal dilator with cutting blade [\ meas- 
urement). 



Fig. 143 — A. Cicatricial stenosis before 
treatment ; B, the same after use of cutting 
dilator (Lennox Browne). 



the acid nitrate of mercury diluted with 5 parts of water, 
application of nitrate of silver being made on alternate days. 
After a time, when the process of repair is beginning to set 
in, these applications become painful and should be omitted, 



252 DISEASES OF THE NOSE, THROAT, AND EAR 

but insufflations of Formula 58 should be continued until 
the larynx presents its normal appearance. Should partial 
stenosis occur as the result of cicatricial contraction, the 
laryngeal stenosis may be overcome by the use of laryn- 
geal bougies or some suitable cutting instrument (Fig. 142). 

Tubercular Laryngitis. — Tubercular laryngitis is a chronic 
laryngitis due to the specific poison resulting from the 
presence of the tubercle bacilli. It is sometimes called 
laryngitis phthisica and throat consumption. 

Etiology. — It is generally secondary to pneumonic phthisis, 
although this is a debatable question. In most all instances 
the cellular tissue of the larynx is the structure first affected. 
The inoculation in this locality may occur through the 
lymph-channels, the blood-vessels, or by means of an 
abrasion in the mucous membrane exposed to tubercular 
sputum from the lungs. Inoculation of tuberculosis in 
syphilitic ulcers in the larynx has been observed, and it is 
stated that the presence of simple catarrhal laryngitis, either 
acute or chronic, is a predisposing cause of tubercular 
laryngitis when tuberculosis of the lungs is already present. 
Hospital reports, mostly German, vary from 6 to 50 
per cent, as to the frequency of laryngeal involvement in 
post mortems on individuals dead from pneumonic phthisis. 
Probably about one-third of the cases of lung consumption 
in this country, sooner or later, develop laryngeal lesions. 
That the larynx is not frequently inoculated by the inspira- 
tion of pulverized dried phthisic sputum is probably due to 
the fact that under ordinary circumstances particles of dust 
in inspired air are arrested within the nose or pharynx and 
do not reach the larynx ; and in this connection it is interest- 
ing to note that certain observers have claimed that those 
suffering from atrophic rhinitis are proportionately more 
frequently attacked by pneumonic phthisis than those with 
normal noses. Most frequently tubercular lesions of the 
larynx occur on the same side as the lung most affected by 
the disease, although this is not invariably the case. 

Pathology. — The lesions in the larynx are similar to 
those found in tuberculosis elsewhere : Tubercles are formed 
and the bacilli are disseminated into the surrounding tissues, 
partly by their own multiplication and partly by lymph- 



d/seasils of the larynx 



253 



currents, so that the extent of the tissue involvement is 
always much greater than it appears to the eye of the 
observer. As the result of nature's efforts to limit the 
spread of the infection, leukocytes appear about the affected 
area and a reticulum of connective tissue is formed. Degen- 
eration of the tubercle then occurs as the result of lack of 
nutrition, and manifests itself either as a local sclerosis or as 
a tissue necrosis, with a resulting ulcer that may involve 
not only the mucous membrane and cellular tissue but also 
muscles and cartilages as well. Bacilli appear in the 
discharges and the tuberculous process extends. 

In tuberculous individuals there is often observable an 
ashy gray appearance, differing from the ordinary paleness 





Fig. 144.- — I>aryngeal tuberculosis with 
characteristic pyriform swelling of the 
arytenoid cartilages (Lennox Browne). 



Fig. 145. — First stage of tuberculosis of 
larynx. Ulceration of right cord and swell- 
ing of interarytenoid region with formation 
of folds. May be early ulceration here 

(Sahli). 



of anemia of mucous membranes at the junction of the hard 
and soft palate. The same color is also less frequently 
observable in the larynx. There is sometimes slight local- 
ized congestion of the cords, one of which may be partially 
paralyzed and sluggish in its movements from the pressure 
of a hypertrophied tuberculous lymphatic upon the recurrent 
laryngeal nerve. The voice under such circumstances is 
somewhat aphonic and perhaps slightly hoarse at times. 

Characteristic lesions are submucous infiltrations, gener- 
ally club-like in shape, sometimes involving one or both 
arytenoids, '* pyriform arytenoids " (Fig. 144), orproducingthe 
" turbine-shaped " epiglottis. Minute tubercles break down 
upon the cords, producing ulcers that give the cords a 
" moth-eaten " appearance (Fig. 145). Fungus-like thicken- 



254 DISEASES OF THE NOSE, THROAT, AND EAR 

ing of the interarytenoid mucous membrane is common in 
laryngeal tuberculosis. Deep ulcerations involving necros- 
ing cartilage is a later stage, from which there are few re- 
coveries. Usually the concomitant lung lesions have also 
reached an advanced stage, and the fatal end is hastened by 
the patient's inability to swallow or even breathe without 
pain. 

Differential Diagnosis. — In certain cases the differential 
diagnosis between malignant ulceration and tuberculosis is 
one of extreme difficulty. In malignant ulceration the in- 
flamed and reddened appearance of the unaffected mucous 
membrane of the larynx contrasts strongly with the pale 
and anemic appearance in tuberculosis. There is the lung 
involvement in tuberculosis, the greater involvement of the 
cervical glands in malignant disease. There are two other 
conditions of the larynx that sometimes closely simulate 
tuberculosis in appearance — syphilis and lupus. 

It should be borne in mind that tuberculosis is sometimes 
engrafted upon a syphilitic ulcer. Syphilitic ulcer of the 
larynx follows the breaking down of a gumma. There is 
usually a history of syphilis or syphilitic lesions may be 
found upon the body elsewhere. The diagnosis will be 
cleared up by the administration of antisyphilitic remedies. 

Lupus is tuberculosis of the larynx resulting from the 
inoculation of the larynx with an attenuated tubercle bacilli, 
is usually secondary to lupus of the mouth or pharynx, 
and is an extremely rare disease. 

Symptoms. — In the earlier stages of the disease there are 
practically no symptoms except perhaps occasional transi- 
tory hoarseness or very slight aphonia. These voice 
symptoms increase as the disease progresses until the voice 
may be a mere whisper and very hoarse. The interference 
with vocahzation may be due to pressure upon the recur- 
rent laryngeal nerve, interarytenoid thickening interfering 
mechanically with the approximation of the cords, tuber- 
cular infiltration of the muscles or involvement of the 
arytenoid articulations or ulcerations upon the cords. 
Thick, tenacious mucus coughed up from the trachea or 
supplied by the larynx if ulcers are present may adhere for 
a time to the cords and interfere with vocalization until 



DISEASES OE THE LARYNX 255 

dislodged. This usually occurs after several ineffectual 
efforts — the mass being expelled through the mouth with 
considerable force. 

A hacking, dry cough is often present when there is 
interarytenoid thickening. Wiien ulceration is present the 
secretions are more abundant and contain the tuberculous 
bacillus. The secretions are sometimes streaked with 
blood, but abundant hemorrhage from tubercular ulcerative 
laryngitis probably never occurs. 

Pain on swallowing occurs where the infiltration of the 
arytenoids or epiglottis is great, and there is a sense of 
obstruction in deglutition as if from a " lump in the throat." 
Deglutition becomes exquisitely painful when ulceration 
has occurred upon the epiglottis or in the aryepiglottic fold. 
Ulceration within the larynx gives rise to little or no dys- 
phagia and liquid gives rise to less pain than solid food. 
So exquisitely painful is the act of swallowing in some 
cases that patients have been known to refuse food or drink 
for days rather than endure the torture of swallowing it. 

Prognosis. — Ciires have been reported even in the ulcera- 
tive stage of the disease, but the progress of the disease in 
all cases is usually slow and tedious. Harland states that 
the chances of improvement in tuberculosis of the larynx 
are nearly as follows : 

" I. Larynx free from disease; prognosis so far good. 
2. Congestion of cords (vasomotor) ; prognosis good ; 
examination of lungs indicated. 3. Superficial ulcer, local- 
ized infiltration or tuberculoma ; chances of improvement 
about 60 per cent. 4. Deep ulceration ; chances of im- 
provement about 38 per cent. 5. Lesions of vocal cord, 
ventricular band, or interarytenoid fold ; chances of improve- 
ment about 89 per cent. 6. Lesions of epiglottis or aryepi- 
glottic fold ; chances of improvement about 29 per cent." 

Treatment. — The treatment of the milder forms of the 
disease should be largely systemic. It should be borne in 
mind that the disease only does great harm when it causes 
pain or prevents the taking of food, and that occasionally 
large ulcers have been seen to heal with practically no local 
treatment. Cutting operations with the expectation of 
eradicating the local disease are probably, in most cases, 



250 DISEASES OF THE NOSE, THROAT, AND EAR 

worse than useless, as it is impossible to know how far the 
bacilli have penetrated the apparently sound tissue about a 
lesion. Of course, if tubercle papilloma in the interary- 
tenoid or other regions attain such a size as to produce dysp- 
nea, as they rarely do, an effort should be made to remove 
them with forceps or snare ; otherwise those growths should 
be let alone. They frequently recur after removal. 

Ulcerations should be cleansed with equal parts of 
Dobell's solution and peroxid of hydrogen by means of 
a spray from an atomizer. After the parts have been 
cleansed the ulceration should be dusted by means of a 
powder-blower with Formula 59. 

Owing to the bulk of the tannic acid contained in this 
powder the amount of morphin in the quantity thrown by 
the powder-blower into the larynx is very minute, but if 




Fig. 146.— Harland's laryngeal curet. In order toreach all localities in the larynx the 
curet is provided with a flexible shaft that can be bent to enter any ordinary larynx, and has 
an edge that cuts upward and backward, and another that cuts downward and forward. 

for any reason the morphin is objectionable, it may be 
omitted from the formula. 

Excessive pain on swallowing may, of course, be relieved 
by cocainizing the larynx, either with an atomizer or a 
laryngeal applicater. A lozenge containing ^ to J gr. of 
cocain, dissolved in the mouth before meals, yields fairly 
satisfactory results. However, for the relief of painful 
deglutition no remedy yields such satisfactory results, 
eveiything considered, as orthoform. 

This nearly insoluble substance has the property of pro- 
ducing analgesia when applied to exposed nerve-endings. 
It is, therefore, especially valuable as an application to irri- 
table ulcers after they have been cleansed with Dobell's 
solution and peroxid of hydrogen. Its anesthetic effects 
are increased by a previous application of a solution of 



DISEASES OE THE LARYNX 2^7 

cocain and persist for four or five hours. When insufflated 
into a tuberculous larynx the powder produces a momen- 
tary smartinf;^, followed by analijcsia more or less complete, 
which persists as long as the powder adheres to an abraded 
surface or an ulcer. The powder possesses decided anti- 
septic qualities and promotes the healing of tuberculous 
ulcerations. It has little effect upon the unbroken mucous 
membrane. 

A nurse or one of the patient's friends can be taught to 
insufflate orthoform into a tuberculous larynx ten minutes 
before each meal, and in many instances thus secure com- 
plete relief from dysphagia. Orthoform is said to be non- 
toxic, and hence may be used locally in liberal quantities. It 
may, of course, be prescribed in the form of a lozenge, but 
with not nearly as satisfactory results as when the powder 
is insufflated into the larynx. 

A spray of menthol in albolene (logr. to i ounce) may 
be used by the patient inhaling each time he compresses 
the bulb of the atomizer. It yields fairly satisfactory 
results in a few^ cases. However, before using any applica- 
tion to the larynx himself the patient should, of course, 
cleanse it as thoroughly as possible under the circum- 
stances by inhaling the spray from an atomizer containing 
equal parts of Dobell's solution and peroxid of hydrogen. 

Fluids, especially if iced, commonly cause much less 
pain on swallowing than solids, and iced milk can some- 
times be taken through a tube with the patient's head 
hanging over the bed when it would be much more painful 
to sit up and drink the fluid ; but in extreme cases the 
stomach-tube and rectal alimentation will have to be em- 
ployed. 

Syrupi lactic acid is a remedy that is said to have the 
property of destroying tuberculous structures without 
attacking the surrounding sound tissues. Its application 
to a tuberculous ulcer is so painful that its use should 
always be preceded by thoroughly cocainizing the larynx 
with a lo per cent, solution of cocain. The applications 
can be made at intervals of four or five days and be pre- 
ceded, if necessary, by cureting the cleansed ulcer. It is 
best to commence by lightly touching the parts with a 25 
17 



258 DISEASES OF THE NOSE, THROAT, AND EAR 

per cent, solution of the syrupy acid and gradually increas- 
ing the strength from visit to visit as the patient becomes 
accustomed to the pain. The remedy undoubtedly hastens 
cicatrization of ulcers and, it is claimed, promotes the ab- 
sorption of deposits. It should be used with judgment 
and caution, as the edema is frequently increased for a day 
or two if lactic acid is applied too freely or an attempt is 
made to " rub in " the remedy upon the floor of a tuber- 
culous ulceration. 



T^¥^eA«Z 







m'f--^ 



'Wa 




Fig. 147.— Pachydermia laryngis (X 60) : i, Cylindric epithelium; 2, area of transition 
into (3) stratified squamous epithelium ; 4, papillary body ; 5, dilated blood-vessels of tunica 
propria; 6, mucous glands. (Diirck.) 

Laryngeal Tumors. — The tumors most commonly met 
with in the larynx are papilloma, fibroma, angioma, 
myxoma, cyst, sarcoma, and carcinoma. 

Symptoms. — The most noticeable symptom is mechanical 
obstruction to breathing and phonation proportionate to its 
size and location. If the tumor is small and situated upon 
a vocal cord, dysphonia results from interference with its 
vibration, while, if the growth is situated in the anterior 
commissure between the cords, aphonia results from the 
tumor preventing their approximation. If, however, the 



DISEASES OE THE LARYNX 259 

tumor is small and situated above the vocal bands, but 
slight, if any, subjective symptoms will be noticed. As the 
growth of a laryngeal tumor increases dyspnea increases 
and asphyxia may suddenly occur unless prompt relief is at 
hand. Cough is not usually present unless the growth is 
of such a character as to vibrate in the breath-current and 
titillate, as it were, the interior of the larynx (Fig. 148), 
when cough and laryngeal spasms may occur. Chronic 
laryngitis is usually present as the result of laryngeal 
tumors. 

Papillomata found in the larynx of children offer some 
peculiarities. They are soft and usually multiple. They 
are usually associated with a catarrh of the nasopharynx 
and hypertrophied tonsils, and sometimes disappear under 
the application of astringent powders to the larynx and 




Fig. 148. — Pedunculated fibroma upon the under surface of the left vocal cord ; position 
during inspiration (v. Zeimssen). 

successful treatment of the nasal and pharyngeal affection, 
to the existence of which in many instances they seem 
largely due. 

The papillomata of adults are harder than those of chil- 
dren, and are usually situated on the vocal cords or ventric- 
ular bands. 

Etiology. — Any long-continued irritation of the laryngeal 
mucous membrane may result in hyperplasia and the 
growth of warts. When the result of long-continued 
catarrhal inflammation, papillomata usually occupy the 
interarytenoid space and the posterior extremities of the 
vocal cords. 

Papillomatous growths are sometimes seen about tuber- 
cular ulcerations and upon the mucous membrane covering 
gummata and tumors lying underneath the laryngeal 



26o DISEASES OF THE NOSE, THROAT, AND EAR 

mucous membrane. Under such circumstances a piece re- 
moved by the forceps from the larynx may under the 
microscope present the appearance of papilloma, and in its 
deeper parts that of carcinoma, and hence give rise to the 
erroneous impression that papillomata are prone to gen- 
erate into carcinomata. 

In case the papillomata occur in connection with laryn- 
geal phthisis, syphilis, or a laryngeal tumor, they result 
from the irritation to the laryngeal mucous membrane 
caused by the primary disease. 

Laryngeal carcinomata may be divided into intrinsic and 
extrinsic. Intrinsic carcinoma attacks the ventricular bands, 




Fig. 149. — Papilloma of larynx (Stoerck). 

the ventricle, and the vocal cords. Extrinsic has its origin 
upon the epiglottis, the arytenoid folds, and the pyriform 
sinus. 

In extrinsic carcinoma the lymphatic glands are affected 
almost from the commencement, the disease rapidly ad- 
vances toward a fatal termination, and is rarely, if ever, 
cured by operation. 

Intrinsic carcinoma is a less grave affection ; its advance 
is less rapid and the neighboring lymphatics often remain 
for a long time uninvolved. Extirpation, either partial or 
entire, should not be undertaken except the disease be 
intrinsic and limited entirely to the larynx. 

Treatment. — Tumors springing from the epiglottis can 
usually be removed by means of a Jarvis snare with a 



DISEASES OF THE LARYNX 26 1 

curved lip, while cysts may be opened with the laryngeal 
lancet (Fig. 141) and their contents allowed to escape, after 
which the end of a probe on which nitrate of silver has been 
fused should be passed into the cyst and its interior thor- 
oughly cauterized. Papillomata (Fig. 149) and soft or pe- 
dunculated tumors should be removed by means of the laryn- 
geal forceps (Figs. 151, 152), if necessary picking off piece 
after piece until the entire tumor has been removed. In 
every case of tumor of the larynx the emergencies of the 
case govern the operative procedures necessary. If the 
removal of the tumor is very urgent to prevent suffocation, 




Fig. 150. — Carcinoma of the larynx (Stoerck). 

and the patient's throat is too irritable to permit instru- 
mental interference without danger of fatal result from 
induced spasm of the glottis, tracheotomy should, of course, 
be performed before the removal of the tumor is attempted. 
If the growth is malignant, extirpation of the larynx, either 
in part or as a whole, gives the only hope of bringing about 
a cure of the affection. The operation should be performed 
as soon as a certain diagnosis is established. In inoperable 
cases the x-x'd.y may be used. 

It is generally useless to attempt the removal of any 
laryngeal growth with the forceps until the larynx has been 
so thoroughly cocainized that no spasm occurs upon the 



262 DISEASES OF THE NOSE, THROAT, AND EAR 

introduction of a probe. This can almost always be accom- 
plished by painting the interior of the larynx with a 10 per 
cent, solution of cocain by means of a laryngeal applicator 




Fig. 151.— Cusco's laryngeal forceps. 



until no spasm occurs when the applicator or probe is intro- 
duced into the larynx. In the larynx cocain anesthesia 
occurs more rapidly than in the nose, but lasts for only a 
short time. 




152. — Mackenzie's laryngeal forceps. 

Foreign Bodies in the Larynx. — Smooth substances, such 
as small pebbles, shoe-buttons, seeds of various kinds, etc., 
are not apt to lodge in the larynx, but are either removed 



DISKASES 01' TJIK LARYNX 263 

by a fit of coui^hin^ or drop into the trachea. Substances 
with sharp points, hkc fish-bones or pins (Fig. 153), arc 
often partially imbeded in the tissues of the larynx. 

Treatment. — The foreign body should be removed with 
the laryngeal forceps when possible. In rare cases a wound 
of the interior of the larynx is rapidly followed by edema 
of the glottis. Under these circumstances tracheotomy 
should be performed before any attempt is made to remove 
the offending substance. 

TJiyrotoiny. — This operation consists in the separation of 
the two wings of the thyroid cartilage by means of an 
incision through the angle of the thyroid cartilage, thus 
exposing the interior of the larynx for the removal of 
tumors or foreign bodies that cannot be removed readily 




Fig. 153. — A pin imbedded in the posterior portion of the right vocal cord (Seiler). 

through the mouth. The operation is done under chloro- 
form anesthesia and in the tracheotomy position. 

An incision is made through the skin from the thyro- 
hyoid space to the upper tracheal rings exactly in the 
median line. The underlying structures are divided care- 
fully by means of a knife and a grooved director. The 
thyroid prominence bulges out of the wound and can be 
opened by passing one blade of a stout pair of angular 
scissors through the cricothyroid membrane into the larynx. 
The larynx can also be opened by means of a stout bistoury 
or, when ossified, by means of a Sajous saw (Fig. 66). 
The edges of the wound are now separated Avith retractors 
in the hands of an assistant, and spasm of the laryngeal 
muscles, which always occurs when the larynx is opened, 



264 DISEASES OF THE NOSE, THROAT, AND EAR 

is controlled by brushing the laryngeal mucous membrane 
with a 4 per cent, solution of cocain. The operation is a 
comparatively bloodless one and exposes in a very satis- 
factory manner the interior of the larynx for the removal 
of a foreign body or a tumor. 

After the removal of the tumor or foreign body the 
severed edges of the cartilage are united by one or more 
catgut sutures and the skin wound brought together by 
sutures of worm-gut Union usually occurs by first in- 
tention, but the ultimate condition of the voice depends 
upon the amount of damage done to the interior of the 
larynx. The removal of a foreign body or small tumor 
is not followed by any very appreciable impairment of the 
voice. 

The after-treatment after removal of a small tumor by 
this method consists in keeping the patient quiet in bed for 
a week or so and forbiddiug the use of the voice. For the 
first few days the diet should be liquids. 

NEUROSES OF THE LARYNX 

Neuroses of the larynx are divided into sensory and 
motor neuroses. 

Sensory neuroses are anesthesia, hyperesthesia, and pares- 
thesia. 

Anesthesia of the mucous membrane of the larynx, 
sometimes accompanying motor paralyses of the larynx, 
is occasionally observed in hysteria and in the insane. 

Hyperesthesia acompanies all forms of laryngeal inflam- 
mation except some forms of early tuberculosis. It is 
frequently present in neurotics. 

Paresthesia manifests itself chiefly as a sensation of chok- 
ing or as of a foreign body in the larynx of hysteric 
individuals. 

These sensations are sometimes the result of disease of 
the pharynx or tonsils, and when this condition exists it 
should receive appropriate treatment. In the mean time 
considerable relief will follow the administration of 10 to 15 
gr. of the bromid of sodium three times a day. 

Motor neuroses are spasm incoordination and paralysis of 
the laryngeal muscles. 



D/SKASES OF THE LARYNX 265 

Spasm of the laryngeal muscles appears in three forms — 
si^asmodic cough, spasm of the adductors, and spasm of 
the tensors of the cords. 

Spasmodic laryngeal cough or laryngeal chorea is a condition 
commonly described under this heading, although other 
respiratory muscles beside those of the larynx are involved 
in the paroxysms of coughing, which is of a peculiar bark- 
like character resembHng that of a big dog. The parox- 
ysms of coughing occur at frequent intervals during the 
day, but cease during sleep. The disease occurs more 
frequently in neurotic females than in males. It is not 
associated with chorea in any manner whatever, nor is there 
any evidence of laryngeal inflammation on examination 
with the laryngoscope. 

Trcatmoit should be directed toward improving the 
individual's general health. Good results generally follow 
the prolonged use of some nerve tonic like pil. sumbul 
comp., one after meals, and at bedtime, but quicker relief 
can generally be obtained from bromid of sodium, 10 to 15 
gr., after meals and at bedtime. 

The use of the induced current, one sponge on the skin 
on each side of the larynx, does good probably from the 
impression it makes on the mind of the patient. To 
accomplish this the electricity should be used as strong as 
it well can be borne by the patient. Aside from the use of 
electricity local treatment is not indicated. 

Spasm of the Tensors of the Vocal Cords. — This is a rare 
condition affecting singers, actors, and orators, somewhat 
analogous to the spasm of the muscles observed in the 
muscles of the hand in writers' cramp. 

Syviptoms. — The voice is suddenly lost, possibly in the 
midst of a sentence, by a spasm (sometimes painful) of the 
cords. The greater the effort to speak or sing, the tighter 
and longer the spasm. After a moment the spasm subsides 
and the voice is normal for several minutes, when another 
spasm may occur. Examination with the laryngoscope 
during a spasm shows the cords tightly approximated in 
the position for vocalization. There may or may not be 
slight hyperemia of the larynx. 

Treatment consists in rest of the voice, preferably in the 



266 DISEASES OF THE NOSE, THROAT, AND EAR 

country or at the seashore, tonics, and attention to personal 
hygiene. 

Spasm of the adductor muscles or laryngismus stridulus, 
false croup, generally involves the crico-arytenoidei externi 
and the arytenoideus. 

Etiology. — The condition usually occurs in neurotic chil- 
dren under three years of age. There is frequently some 
pathologic condition of the nose and nasopharynx that ren- 
ders the nerve-endings of the upper respiratory tract more 
irritable, and in neurotic children is sufficient to induce a 
reflex spasm of the adductor muscles of the vocal cords from 
trifling causes, such as a slight lowering of the temperature 
during the night after the child has gone to bed, kicking 
off the bedclothing, etc. 

In some adults the entrance of a small particle of food 
or dust into the larynx produces a condition similar to 
laryngismus stridulus. In such individuals applications to 
the nasopharynx of iodin-potassium-iodid-glycerin ; solu- 
tions of sulphate of zinc or any of the other routine applica- 
tions to the nasopharynx may be followed by alarming 
spasms of the laryngeal adductor muscles if a drop of the 
solution by any mischance happens to drip into the larynx. 
The same thing occurs in such individuals after the applica- 
tion of an ordinary remedy to the larynx. 

To the inexperienced laryngologist the symptoms are 
sufficiently alarming. After the laryngeal application the 
patient suddenly becomes cyanosed and, with protruding 
eyeballs, clutches at his throat. The patient gasps. The 
respiration is loudly "crowing," Hke that of a child with 
laryngismus stridulus, and death from suffocation seems 
imminent. These alarming symptoms disappear as suddenly 
as they occurred if the patient makes an effort to pronounce 
words. The practitioner in a loud voice should command 
the patient to say " One, two, three," or in an equally loud 
and commanding voice inquire, " What is your name ?" 
When the patient makes an effort to answer the spasm of 
the glottis vanishes and breathing becomes at once normal. 

In the first stages of locomotor ataxia there is occasion- 
ally a history of spasms of the adductor muscles resembling 
laryngismus stridulus, and in an adult such a history in the 



DISEASES OF THE LARYNX 267 

absence of foreign bodies gainini^ entrance into the larynx 
should be a sufficient warrant to search for other symptoms 
of this disease. 

SyniptoDis. — In children the attack appears suddenly dur- 
ing the night in apparently healthy children. The child 
suddenly sits up in bed gasping for breath. At the height 
of the attack it is markedly cyanosed, when suddenly there 
is a deep inspiration and the symptoms rapidly disappear. 
There remains no symptoms of laryngeal inflammation 
except that during the day there may be a slight " croupy " 
cough. 

Prognosis. — The attacks of false croup not infrequently 
recur at intervals for weeks or months. It is said that in 
very young children the attacks sometimes terminate in 
eclampsia or convulsions. 

Treatment is directed to the prompt relief of the laryn- 
geal spasm. This can sometimes be accomplished by mak- 
ing the child sneeze by tickling the nose with a feather or 
a pinch of snuff. When sneezing occurs the spasms cease. 
The inhalation of a few drops of chloroform from a hand- 
kerchief is generally effective. Extreme heat or cold to 
the skin over the larynx or 3 drops of adrenalin chlorid 
solution (i : looo) hypodermically will sometimes relieve 
the spasm. Any or all of these measures should be tried 
while a hot mustard-bath is being prepared. The child 
should be placed in this and, after remaining for a few 
moments, taken out and carefully wrapped in a warm woolen 
blanket before being replaced in bed. For very severe 
attacks Coakley advised the following as a rectal injection : 

R Chloralis hydratis, gr. vj ; 

Potassae bromidi, gr. x ; 

Aquse, q. s. ad. fgj. — M. 

Sig. Use as a rectal injection for a child six months old. 

As a prophylactic between the attacks all sources of irri- 
tation should be sought for and removed. These may 
include errors of digestion, carious teeth, or nasopharyngeal 
disease. Hearty suppers and lunches at bedtime should be 
forbidden. 

Somnos in J-teaspoonful doses should be given eveiy 



268 DISEASES OF THE NOSE, THROAT, AND EAR 

three hours during the day for a week or more or 
until the immediate danger of a recurrence of the attack 
seems to have disappeared. The child should then take 
syrup of the iodid of iron after meals, i drop for each year of 
its age, up to I o drops, with or without cod-liver oil. Syrup 
of the hypophosphites may be substituted for the iron at 
the physician's discretion. 

In adults and nervous children sodium bromid answers a 
useful purpose. Pil. sumbul comp. or some other combina- 
tion of iron, valerian, and asafetida may be given. 

Laryngeal Vertigo or Epilepsy. — This is a rare laryngeal 
neurosis occurring more frequently in males than females. 

Etiology. — The disease occurs in neurotic individuals, and 
the symptoms are probably due to an incoordination of the 
respiratory centers implicating the laryngeal muscles in such 
a manner as to produce closure of the glottis. 

Symptoms. — The prodromes are a tickling sensation in 
the larynx and a fit of coughing. The patient draws a 
long breath. The glottis closes and the inspired air is con- 
fined in the lungs. There follows vertigo, cyanosis, and 
sometimes loss of consciousness. The " fit " then passes 
off, to be repeated at intervals. 

The laryngoscope shows no characteristic lesion ; a nor- 
mal larynx or sHght catarrhal inflammation being commonly 
observed. Disease of the nose and pharynx catarrhal in 
character is frequently present in such cases. 

Prognosis. — The prognosis as regards life is favorable. 
There may, however, be a recurrence of the attacks of laryn- 
geal vertigo extending over a period of years. 

Treatment. — The treatment, like that of other neuroses, 
consists in hygienic measures calculated to improve the in- 
dividual's general health, and if the attacks are frequent 
the administration of antispasmodics. Galvanic electricity, 
the positive pole over the larynx, may be employed. 

Paralysis may affect but one laryngeal muscle or pair of 
muscles ; or it may affect several of them at once, and may 
be either unilateral or bilateral. Paralysis of the larynx may 
be divided clinically into paralysis of the adductors, paralysis 
of the abductors, and paralysis of the tensors of the cords. 

Etiology. — The laryngeal muscles receive their nerve-sup- 



DISEASES OE 77/ E 7.ARYNX 269 

ply by means of two branches of the pncumof^astric — the 
superior laryn<^eal and the recurrent hiryngeal. The pneumo- 
gastric, at its origin, is a sensory nerve, but receives motor 
fibers from the spinal accessory, so that it possesses both 
sensory and motor functions above the point where the 
superior laryngeal is given off. Paralysis of the laryngeal 
muscles may be due, Hke paralysis of other muscles, to (i) 
disease or injury of the brain involving the cerebral portion 
of the nerves that supply the larynx; (2) injury or pressure 
of the nerves below their cerebral portion ; (3) an abnormal 
condition of the muscles themselves, and (4) some systemic 
dyscrasiae, like rheumatism or hysteria, because of which 
the muscles are unable to respond to nervous influence. 




Fig. 154. — Bilateral paralysis of the adductors (crico-arytenoid lateralis and arytenoideus). 
Appearance in attempted phonation (Lennox Browne). 

Adductor Paralysis. — Adduction of the vocal cords being 
performed by means of the lateral crico-arytenoid muscles 
and the arytenoideus muscle, paralysis of these muscles 
causes the cords to remain in a state of extreme abduction. 
This condition is in most instances due to hysteria, rheuma- 
tism involving either the muscles or the cricothyroid joint, 
or chronic poisoning by lead or arsenic. If bilateral paralysis 
exists, the vocal cords will be seen in the laryngeal mirror 
separated to the utmost degree (Fig. 154), and the voice 
will be completely lost. If paralysis of the arytenoideus 
muscle alone exists, which, however, is rarely the case, the 
anterior two-thirds of the vocal bands can be approximated ; 
but a triangular space will be left behind the vocal processes 
during phonation, through which the breath escapes and 
renders the voice feeble, and its use in singing and speaking 



270 DISEASES OF THE NOSE, THROAT, AND EAR 

both fatiguing and unsatisfactory. This condition of affairs 
may occur during the course of either acute or chronic laryn- 
gitis from extension of the inflammation to the arytenoideus 
muscle (Fig. 155). 

In unilateral adductor paralysis only one cord is seen in 
extreme abduction during phonation, and the opposite cord 
will be observed to pass beyond the median line, so as to 
approach as near as possible to its motionless companion 
(Fig. 156). Although aphonia exists, the whispered words 
are usually perfectly comprehensible. 

Abductor Paralysis. — Abduction of the vocal cords is 
accomplished solely by means of the crico-arytenoid muscle, 




Fig. 



[55. — Bilateral paralysis of the aryte- 
noideus (Lennox Browne). 




Fig. 156. — Unilateral paralysis of ad- 
ductor of left cord. Appearance in at- 
tempted phonation (Lennox Browne). 



and hence the complete paralysis of both of them will pre- 
vent separation of the cords, and almost completely prevent 
the entrance of air into the lungs ; a mere slit posteriorly, 
which represents the action of the arytenoideus, being the 
extent of the available breathing space. During expiration, 
however, the vocal cords are forced apart by the ascending 
air-current impinging upon their under surfaces, which curve 
upward from the sides of the larynx. The voice is unim- 
paired in this affection, but where complete paralysis of the 
abductors exists it may be necessary to perform tracheotomy 
to prevent suffocation occurring as the result of slight inflam- 
matory swelling of the mucous membrane of the larynx as 



DISEASES OF THE LARYNX 



2^1 



the result of a cold. Paralysis of the abductors may result 
from a tumor in the brain involving the origin of both pneu- 
mogastrics and spinal accessory nerves. In such cases the 
abductors of the larynx are first paralyzed, but as the tumor 
increases in size paralysis of the muscles of the larynx 
results, the cords assuming the " cadaveric position " (Fig. 
157). Paralysis of both posterior crico-arytenoid muscles 
may result also by pressure 
upon the recurrent laryngeal 
nerves by an aneurism, a goi- 
ter, or carcinoma of the esoph- 
agus, or the lesion may be 
located in the muscles them- 
selves. When unilateral paral- 
ysis only is present, the af- 
fected cord will be seen to 
remain always in the median 
hne, even during forced in- 
spiration, but subjective symp- 
toms will be so slight as to 
hardly attract attention. The 
voice will be perfect and the 
breathing space ample, except 
during violent exercise (Figs. 
158, i59). 

Two forms of paralysis of 
the tensors of the vocal cords 
are met with, one due to 
paralysis of the cricothyroid 
muscle, which is rare, and the other one to paralysis of the 
thyro-arytenoids, which is not uncommon. Paralysis of the 
former muscle causes the edges of the cords to assume a 
wavy line, touching each other at irregular intervals during 
phonation (Fig. 160), while the voice is coarse and remains 
always at the same pitch. The upper surface of the cords 
appears convex during expiration and concave during 
inspiration. When the thyro-arytenoids are paralyzed, the 
cords assume a slightly curved appearance when an attempt 
is made to bring them together during phonation, and a 
slight space remains between their centers (Fig. 161). The 




J^s^ 



Fig. 157. — Appearance of the normal 
larynx after death, showing the "cadav- 
eric position" of the vocal cords. 1'his 
is also their position in quiet breathing 
(Lennox Browne). 



2/2 DISEASES OF THE NOSE, THROAT, AND EAR 

voice is husky, high pitched, and weak, the air escaping 
through the elHptic space between the cords, necessitating 
great effort on the part of the patient in order to speak. 

Treatment. — The cause of the paralysis should be care- 
fully sought and treated, the success of the measures 
adopted depending, of course, upon the nature of the primary 
ailment In suitable cases strychnin should be administered 
in gradually increasing doses until the limit of , toleration 
has been reached, and galvanism or faradism used by means 
of the larjmgeal electrode (Fig. 162), applied within the 
larynx as near as possible to the affected muscles. An 
ordinary sponge electrode is held by the patient or an 





Fig. 159. — Unilateral paralysis of the 
left abductor. Appearance in phonation. 
Fig. 158. — Bilateral paralysis of the The affected cord is seen to be in the 

abductors (crico-arytenoidei postici). cadaveric position, while the other is ad- 

Appearance with deep inspiratory effort vanced beyond the median line (Lennox 

(Lennox Browne). Browne). 

assistant upon the skin over the larynx, while the operator 
guides the tip of the electrode into the larynx, watching its 
progress with the laryngoscope, until it is in the desired 
position. The finger-rest on the top of the handle of the 
instrument is now depressed and the current passes. Each 
application should last but a few seconds, and be repeated 
three or four times at each sitting, at intervals of one or two 
minutes. Electricity may be used in this manner every 
other day, the current used not stronger than is sufficient 
to secure contraction of the affected muscles. At first the 
mere introduction of the electrode into the larynx causes 
retching and gagging, and it may be necessary to apply a 



DISEASES OF THE LARYNX 



273 



10 per cent, solution of cocain to the interior of the larynx 
by means of a pledget of cotton wrapped about the end of 
a probe and dipped into the solution in order to anesthetize 
the parts sufficiently to admit of free manipulation at the 
first sitting. After a few trials, however, the parts become 




Fig. 160. — Bilateral paralysis of the 
thyro-arytenoidei and of the arytcnoideus 
(Lennox Browne). 




Fig. 161. — Bilateral paralysis of the 
sphincter of the glottis (thyro-arytenoidei) 
(Lennox Browne). 




Fig. 



[62. — Mackenzie's laryngeal 
electrode. 



more tolerant and applications can be borne, in the majority 
of instances, without trouble. 

Diphtheria is an acute infectious disease characterized by 
a pseudomembrane which usually appears in the fauces, and 
is associated with a rapid pulse, moderate elevation of 
temperature, and depression. 

18 



2/4 DISEASES OF T^E NOSE, THROAT, AND EAR 

Etiology. — Diphtheria is endemic in all large cities, 
especially in the' more crowded localities, and from time to 
time becomes epidemic, spreading to the outlying districts. 
It is more prevalent in the spring, autumn, and winter than 
in the summer. The specific cause is the Klebs-Loffler 
bacillus. 

Pathology. — The location and extent of the pseudomem- 
brane varies in each case. It may be limited to the tonsils or 
it may cover the entire fauces and extend into the nares and 
the larynx. It sometimes extends through the Eustachian 
tubes to the middle ear. When a diphtheritic membrane is 
forcibly removed it invariably leaves a bleeding surface. 

The bacilli are deposited in the fauces first and cause the 
membrane to become red, inflamed, and swollen. The poison 
kills the superficial layer of epithelial cells, which undergo 
coagulation necrosis. There is a migration of white blood- 
cells, which also undergo coagulation necrosis. These proc- 
esses may only extend through the superficial layer of the 
mucous membrane, but sometimes extend deep into the 
tissues and produce gangrenous ulcers. The color of the 
pseudomembrane is gray or grayish white at first. It some- 
times becomes yellow, but more often is white and flaky, like 
leaf-lard ; it may also assume a dirty brown color, due to 
hemorrhage or to the local use of iron solutions. 

Post mortem, the heart and blood-vessels show degenera- 
tive changes. The heart may contain a blood-clot. The 
lungs frequently show evidence of fibrinous pleurisy, bron- 
chopneumonia, or capillary bronchitis. The liver and spleen 
show little if any change. The kidneys frequently show 
cloudy swelling. Degenerative processes have also been 
found in the nerve-trunks. 

Classification. — Diphtheria may be classified as viild, well 
marked^ severe, and malignant. 

When classified according to location, as fazicial, nasal, 
and laryngeal. There nearly always is, or has been, some 
evidence of the disease in the fauces when either nasal or 
laryngeal diphtheria exists. 

Symptoms. — In some cases of diphtheria there are very 
few or no symptoms at all, except a slight indisposition on 
the part of the child, and the true nature of the disease may 



DISEASES OE 77/ E LA7<yNX 275 

never be recoi^iiizcd unless by accident. The ordinary at- 
tacks of diphtlieria, however, usually bei^in with chilly 
sensations up and down the spine ; occasionally with a dis- 
tinct chill and rarely with a convulsion. This is followed by 
a rise in temperature, quickened pulse, headache, pains in the 
limbs, coated tongue, and sometimes nausea and vomiting. 
Frequently there is stiffness of the muscles of the neck. 
Sore throat and painful deglutition may or may not be 
present. 

The temperature rises to 101° or 103° F. by the end of 
the first day. The pulse is rapid and ranges between 1 10 
and 130. The throat looks red and inflamed at first, then 
there is a deposit of exudate on the tonsils, as a rule, and it 
spreads to the adjacent mucous membrane or may limit itself 
to the tonsils. It is first of a gray or grayish-white color, 
which becomes white or a dirty yellow as it grows older. 
The glands at the angle of the jaw become swollen and 
sensitive. Constipation is frequently present. The urine 
is scanty and high colored. It may show albumin and even 
casts. In the ordinary cases the depression is never pro- 
found and may be absent altogether. 

In favorable cases the disease reaches its height by the 
fifth or sixth day, but the temperature usually falls to normal 
on the third or fourth day. The exudate usually disappears 
by the tenth day and convalescence is well established. 
Paralysis follows but seldom in cases where the exudate is 
limited to the tonsils. 

In severer types of the disease the initial symptoms are 
more pronounced. The depression is marked and comes on 
early. The fauces are greatly inflamed and the tonsils so 
swollen as to meet in the center of the pharynx. They are 
covered by a thick exudate, which impedes respiration and 
articulation. The uvula is swollen and usually covered by 
exudate, which extends forward to the hard palate, and may 
be nearly \ inch thick at the junction of the soft and hard 
palate. The posterior nares are involved by extension of 
membrane up the posterior surface of the uvula. This 
often rapidly extends to the anterior nares and both nostrils 
may become completely plugged by the exudate. There is 
a serous acrid discharge from the anterior nares, which 



276 DISEASES OF THE NOSE, THROAT, AND EAR 

excoriates the skin of the upper lip. The cervical glands 
are markedly enlarged and the cellular tissues swollen and 
edematous. The edema at times extends down upon the 
sternum for several inches. 

The temperature is usually normal or subnormal after the 
second or third day. The pulse is rapid, but soon becomes 
irregular and intermittent. Depression is marked from the 
beginning. The urine is scanty and high colored. Most 
severe cases show albumin and casts. Vomiting is frequent. 
Epistaxis and hemorrhage from the fauces and buccal mem- 
brane are common. The breath is offensive. The patient 
rapidly growls pale and anemic. The skin on the face has a 
drawn and glossy appearance. The child may die in a few 
days, overwhelmed by the diphtheritic poison, or linger for 
several weeks and die of toxemia or paralysis. Any case of 
diphtheria, however severe, may recover or death may 
occur suddenly from paralysis of the heart. When recovery 
takes place convalescence is usually protracted and very 
tedious. Paralysis, either local or general, often supervenes. 

Nasal diplitlicria usually occurs in conjunction with the 
faucial variety or it may follow it. Occasionally it occurs as 
a primary disease ; then the symptoms are milder and the 
exudate is not so extensive. There is always a marked 
tendency to systemic infection whenever the nares are 
secondarily involved. Convalescence is slow and tedious 
in cases that recover. 

Variations from the above descriptions are numerous, for 
no other disease presents so many phases as diphtheria. 

In laryngeal diplitlicria there are hoarseness and a high- 
pitched, metallic cough — the so-called croupy cough — which 
comes on in paroxysms. There is a slight rise in tempera- 
ture and the frequency of respiration is slightly increased. 
As the exudate extends the hoarseness and aphonia increase. 
Finally, the respiration becomes embarrassed and stridulous. 
The auxiliary muscles of respiration are brought into action. 
There is marked retraction in the supraclavicular and 
suprasternal spaces ; also at the substernal space and at the 
border of the ribs. The alae of the nose dilate with each 
respiration. The inspiration is long, deep, and labored, and 
more difficult than expiration, which may be comparatively 



DISEASES OE TJIE LARYNX ^77 

easy. The child is restless, clutching at the sides of the 
bed or anything to raise itself up. The face is pale and 
bathed in a profuse perspiration. The patient has a wild, 
hunted expression. As the obstruction increases cyanosis 
appears, the extremities become purple, the lips and face of 
a livid hue. Sometimes during a fit of coughing membrane 
is expelled as a complete cast of the larynx, trachea, and 
sometimes even of the smaller bronchi. This, as a rule, 
only giv^es temporary relief, for the membrane quickly re- 
forms and all the symptoms return. Unless these cases are 
relieved by intubation or tracheotomy cyanosis becomes 
greater until the child dies asphyxiated. 

Diphtheritic paralysis is a neuritis rather than a true 
paralysis, due to the absorption of the toxalbumins of the 
disease, and generally is proportionate to the severity and 
extent of the acute condition. Rarely marked paralysis 
follows mild attacks — lo to 20 per cent, of diphtheria cases 
are followed by paralysis — which may be either local or 
general. The local variety is usually noticed by the end of 
the first or during the second week. The most frequent 
paralysis is that of the palatal muscles, giving a nasal sound 
to the voice. Fluids are regurgitated during swallowing. 
Strabismus and ptosis are sometimes seen. Paralysis of 
accommodation is not infrequent and paralysis of the tensor 
tympani and stapedius occasionally occur. Facial paralysis 
is occasionally seen. Loss of power in the lower extrem- 
ities with inability to walk is quite common. 

General paralysis usually makes its appearance from the 
fourth to the sixth week, and all the muscles of the body 
may be affected except the sphincters, which are usually 
spared. When all the muscles of the body are affected the 
temperature is usually subnormal, the pulse rapid and inter- 
mittent or very slow. When paralysis is extreme the child 
lays perfectly quiet, unable to move, and frequently unable 
to swallow. There is usually associated with these con- 
ditions a low dragging cough, quite characteristic. 

Systemic Infection or Toxemia. — Some of the mild cases 
have very little constitutional disturbance. On the other 
hand, some patients are overwhelmed by the poison in a 
few days. More often toxemia comes on later when acute 



2J% DISEASES OF THE NOSE, THROAT, AND EAR 

symptoms have subsided and the exudate disappeared. The 
patient appears bright and is apparently convalescing, except 
that his color is noticed to be growing paler. The pallor 
increases daily until the pink hue disappears from the lips, 
lobes of the ears, the palms of the hands, and soles of the 
feet. Exhaustion is extreme. The temperature is usually 
subnormal. The pulse may be slow or very rapid. The 
extremities are cold. The stomach is irritable. The least 
food, even cracked ice, will excite vomiting. The mind 
remains bright and clear. Such cases usually die of toxemia 
and exhaustion, and follow when the local disease has been 
extensive and the depression well marked. 

Complications. — Epistaxis is frequent when the nares are 
involved and, in severe cases, hemorrhage from the fauces 
and buccal mucous membrane. Capillary bronchitis or 
bronchopneumonia is quite common and frequently fatal. 
It occurs during the height of the disease or during con- 
valescence. A fibrinous pleurisy is frequently seen post 
mortem and occurs in conjunction with bronchopneumonia. 
Albuminuria is present in nearly all severe cases and 
occasionally gives rise to alarming symptoms. Suppression 
of urine may follow. Otorrhea is not uncommon, and 
bacilli are found in the discharges for many weeks or even 
months after convalescence is fully established. Pericar- 
ditis and endocarditis may also occur, but are rare. 

Diagnosis. — The characteristic pseudomembrane, which 
leaves a bleeding surface when removed, its gray or grayish- 
white color, its tendency to spread to the adjacent mucous 
membrane, the swelling of the cervical glands, and the 
presence of the bacilli renders the diagnosis in typic cases 
quite easy. 

Mild -cases may be confounded with follicular tonsillitis. 
The anginose variety of scarlatina may present some diffi- 
culty, but the strawberry-tongue, continued high fever, 
absence of the Klebs-Loffler bacilli, and the presence of the 
characteristic scarlatinal rash will exclude diphtheria. 

Bronchopneumonia may be mistaken for the laryngeal 
variety. In pneumonia the respirations are panting and 
rapid ; in laryngeal diphtheria they are long, deep, and 
labored, and the stridor usually well marked. The his- 



DISEASES OE 77/E LARYNX 2/9 

toiy of a fauciiil or nasal cliplitlicria will often clear the 
diaL^niosis. 

Prognosis depends upon the character of the epidemic, 
the type of the disease, and the a^e of the patient. The 
death-rate depends upon the number of laryngeal cases 
requiring operative interference. From this class alone the 
death-rate varies from 30 to 75 per cent. The age of the 
piitient also influences the prognosis. Under one year of 
age, from 50 to 90 per cent, die ; from one to five years of 
age, about 40 per cent. ; from five to ten years, 26 per 
cent. ; from ten to fifteen years, 1 2 per cent. ; over fifteen 
years, 3 to 4 per cent. 

Trcatnioit \'6 divided into (i) prophylactic; (2) local ; (3) 
constitutional ; (4) serum ; and (5) operative. 

PropJiylactic trcatnioit consists in adopting those measures 
that will prevent the spread of the disease. This is best 
obtained by placing the patient in a well-ventilated room, 
preferably on the top floor, and having it isolated. All bed- 
linen, towels, garments, and eating utensils used by the 
patient should be disinfected with a carbolic acid solution 
(5 per cent.) before leaving the room. The attendant's cloth- 
ing should be changed before mingling with other people. 
The physician should wear a linen duster or gown wheji 
visiting the patient. After the patient has recovered the 
room and its contents should be disinfected thoroughly with 
formaldehyd gas. 

Local trcatinoit is to reduce the inflammation, prevent 
the spread of the exudate, and remove what has already 
formed. 

For this purpose peroxid of hydrogen, either in full 
strength or diluted to suit the case, is the best local appli- 
cation. It should be used in the form of a spray or upon 
a cotton swab. 

Many favor astringent solutions, preferably of the iron 
salts ; as. 



R 


Acidi 
Ferri 


i carbolici, 
perchloridi, 












TTLxv 


> 




Glycerin, 


















Aqua, 














aa f^j.- 


-M. 


Sii 


g. To 


be used every 


hour 


or two 


by 


means 


of 


a swab. 





280 DISEASES OF THE NOSE, THROAT, AND EAR 

The solvents — lactic acid, pepsin, caroid, trypsin — have 
many advocates. Lennox Browne is very partial to lactic 
acid applied pure twice daily, and diluted to three or four 
times its bulk with water, applied by the attendant every 
two or three hours. Loffler's toluol solution gives good 
results in some cases, but care must be used in applying it. 
Applications of a solution of nitrate of silver (60 gr. to i 
ounce of water) carefully to the tonsils, palate, and lateral 
walls of the pharynx twice or thrice a day when they are 
alone affected seems to check the extension of the mem- 
brane, but whatever remedy is selected, the practitioner 
should see that it does not increase the inflammation or else 
it will do more harm than good. 

Constitutional Treatment. — Iron and mercury are the two 
drugs we have to rely upon in the treatment of this disease. 
They may be used alone or combined as follows : 

R Tr. ferri chloridi, ^ij ; 

Syr. limonis, 

Glycerin, da l^iij ; 

Aqua, q. s. ad. f^iij.— M. 

Sig. I teaspoonful every hour or two for a child four years old. 

R Hydrarg. chlor. corros., . gr. i-ss ; 

Tr. ferri chlor., fjij ; 

Syr. limonis, 

Glycerin, aa f;^iij ; 

Aqua, q. s. ad. f^iij. — M. 

Sig. I teaspoonful every hour or tviro for a child four years old. 

Instead of the bichlorid, calomel may be given (ro"?^- 
doses every two hours). 

Stimulants are indicated from the beginning ; alcohol is 
undoubtedly the best and should be pushed to its physio- 
logic limit in severe cases. After the exudate disappears 
the whisky should be gradually withdrawn and digitalis 
substituted. When the stomach is irritable, digitalin should 
be given. A child five years old can be given ^ to -^-^ gr. 
or more if necessary. 

Strychnin is also useful, especially in the later stages. 
It can be given in larger doses than is ordinarily employed. 

The Serum Therapy. — To obtain the best results antitoxin 



DISEASES OE THE LARYNX 28 1 

should be used early in the disease, and should be used in 
all cases of suspected diphtheria. 

In mild cases looo units, repeated the next day, will be 
all that is necessary. 

In severe cases it is well to begin with 2000 units as the 
initial dose and repeat every six, twelve, or twenty-four 
hours, until the symptoms begin to subside. When the 
disease persists it is sometimes necessary to give as high as 
20,000 units in divided doses. Antitoxin of the highest 
potency should always be selected, for this gives the maxi- 
mum number of units and the minimum amount of serum. 
It should be injected under antiseptic precautions to pre- 
vent abscesses, which occur in spite of antiseptic precautions 
in about i case in 500. 

Operative intervention is indicated: (i) When the patient 
is cyanosed, together with marked retraction of the supra- 
clavicular, substernal, and subcostal spaces, great rest- 
lessness, cold and clammy sweats. (2) When the symp- 
toms of obstruction in the larynx are not so marked, but 
are rapidly growing worse, intubation preserves the strength 
of the patient. (3) When the symptoms of obstruction are 
not progressing, but are sufficient to prevent the patient 
obtaining rest. (4) In severe cases of nasal and faucial 
diphtheria which develop laryngeal symptoms, intubation 
permits the patient to die easy. 

Intubation. — Select a tube suitable for the age of the 
patient, pass a strong silk thread through the eye of 
the tube (about 20 inches long) and tie the two ends 
together. Then screw the obturator on the introducer and 
place the tube on the obturator. Next, wrap the patient 
tightly in a sheet with his hands at the side to prevent them 
from interfering with the operator. Have the nurse sit in a 
chair and hold the patient upon her lap with his back to her 
left chest and his legs between her knees. The operator 
should sit in a chair facing the patient and place the gag in 
the left corner of the mouth. An assistant standing behind 
the nurse holds the gag and steadies the patient's head 
between his hands. Then the operator, taking the intro- 
ducer in his right hand and holding the thread attached to 
the tube on one finger, rapidly introduces the index-finger 



282 DISEASES OE THE NOSE, THROAT, AND EAR 

of the left hand over the tongue until it is behind the epi- 
glottis and the laryngeal orifice is felt. Then the tube is 
introduced over the tongue, being careful to keep it in the 
median line, until the tip of the finger at the opening of the 
larynx is felt (Fig. 164). Next, elevate the handle of the 
introducer until the tube is in a vertical position and it 
readily slips into the larynx. When the tube is in the 
larynx press forward the button on the top of the introducer, 




Fig. 163. — O'Dwyer's intubation set. 



which releases the obturator. The finger should be placed 
on the head of the tube until the obturator is entirely with- 
drawn. Next, remove the gag, but hold the end of the 
string until you are satisfied the tube is in the larynx and 
the child has obtained relief. This usually requires three 
or four minutes. After respirations become easy, the string 
should be removed or plastered on. the side of the face. To 
remove the string the gag should be placed in the mouth 



DISEASES OE THE L/IRYNX 



2S3 



and the finger should be held on the top of the tube until 
the thread is removed, to prevent removin<^ the tube also. 

Accident Folloivuig Intubation. — Occasionally the mem- 
brane of the larynx becomes detached and is pushed down 
before the tube, completely obstructing^ respiration. It 
does not often happen, but when it does the tube should be 
removed at once by pulling- on the thread attached to the tube. 




Fig. 164.— Intubation: inserting the tube {American Text-book of Diseases of Cliildren). 



This is followed by a forced expiratory effort, which, as a 
rule, expels the membrane. When it does not, trache- 
otomy should be performed immediately. 

After intubation deglutition is difficult, the patient being 
able to swallow only liquids and semisolids. The tempera- 
ture may remain normal, but, as a rule, it rises to 102° to 
F., and remains from i to 2 degrees above normal 
the tube is in the larynx. When intubation gives 



103- 
while 



284 DISEASES OF THE NOSE, THROAT, AND EAR 

perfect relief, the respirations are free and easy and the 
child is entirely comfortable. The coughing attendant upon 
deglutition is sufficient to keep the tube patulous ; but 
should it become occluded or the respirations labored, the 
tube should be removed and cleansed. The reintroduction 
should depend on the character of the respirations after 
removal of the tube. In some cases the patient coughs up 
the tube when it becomes occluded, but when the tube is 
being constantly coughed up it indicates that it is too small 
and a larger size should be used. In favorable cases the 
time for removal of the tube will depend to a great extent 
upon the age of the patient. In children six or seven years 
old the tube may be removed in four or five days ; in 
younger children it should remain five to seven days. When 
death results after intubation it is almost always due either 
to the extension downward of the membrane or to broncho- 
pneumonia. 

An amazing and distressing complication that sometimes 
arises is the inability of the patient to breathe without the 
tube. Children sometimes are obhged to wear the tube one 
hundred and ten days, being entirely well, except that they 
could not breathe without it. The prolonged wearing of the 
tube sometimes produces ulcers in the larynx, which may 
result in complete occlusion of that organ or so constrict 
the lumen that a tracheotomy is necessary. 

Extiibation. — The patient is prepared in the same manner 
as for intubation. The gag is introduced and an assistant 
steadies the head of the patient. The operator introduces 
the left index-finger in the mouth until the tube is felt behind 
the epiglottis. Then with the extractor in his right hand 
the beak is glided over the tongue until the tip of the finger 
is felt at the opening of the tube, when the handle is elevated 
and the beak of the extractor slips into the tube. Then, 
pressing the lever on top of the handle, the blades of the 
beak separate and hold the tube securely until it is with- 
drawn. 

Treatment for Intubation Patient. — When the nares are 
involved they should be syringed several times daily with 
the normal salt solution, otherwise local treatment is un- 
necessary and may be harmful. Steam generated in the pres- 



DISK ASKS OK TJIK LARYNX 285 

ence of the patient is no longer considered necessar}'. 
Constitutionally, stimulants should be given as required, 
preference being given to alcohol and strychnin. Calomel 
in small doses often seems to do good in limiting the inflam- 
mation and preventing bronchopneumonia. Iron mixtures 
are difficult to swallow and are just as well omitted. A 
simple cough mixture containing ammonia carbonas and 
syrup of ipecac often aids in liquefying and expelling the 
mucus from the throat. The most important element in 
the treatment is the nourishment. Milk should be given 
freely. Broths of all kinds, beef-tea, milk-toast, and ice- 
cream may be given freely. 

The method of adjniiiistration of food -AXidi medicines is a 
much-mooted question. Nursing infants take nourishment 
readily from the nursing-bottle. In such cases lowering 
the head makes swallowing easier, as none of the food gets 
into the tube. In older patients it is best to permit them to 
take their food from a glass or in any way they prefer. 
Struggling to make the patient take it in a specified way 
produces exhaustion and is harmful. When children will 
not take food, they should be fed by introducing a soft- 
rubber catheter through the nose into the stomach. 

Tracheotomy is indicated in the same cases as intubation 
and for the same reasons. In addition, it is indicated in 
those cases of intubation where the membrane has extended 
below the tube. It is also performed in cases of foreign 
bodies in the larynx or lower air-passages, malignant or 
benign growths in the larynx, edema of the larynx, fracture, 
gumma, tuberculosis, and spasm of the larynx. 

High and Loiv Operations. — The high operation is an 
opening into the trachea through the cricothyroid mem- 
brane, including in some instances, the cricoid cartilag-e and 

. . . 

the first ring of the trachea. The incision into the trachea 

is above the thyroid isthmus. The low operation is an 
incision of the trachea belozv the thyroid isthmus. In this 
situation the opening into the trachea can be made longer, 
and for this and other reasons is usually the preferable 
operation. 

Tracheotomy has been characterized as one of the most 
easy or one of the most difficult of surgical operations. 



286 DISEASES OF THE XOSE, THROAT, AND EAR 

The difficulties of the operation are enormously increased 
by the presence of a fat short neck and venous conges- 
tion. 

Anesthetic. — In diphtheria and where there is stenosis of the 
larynx from any cause or great inflammation or irritability 
of the larynx and trachea, chloroform is the preferable 
anesthetic. In cases where the supply of oxygen has been 
deficient for some time it seldom requires more than a few 
whiffs of chloroform to produce unconsciousness. The 
chloroform, therefore, should be used with great care. 

Cocain may be employed locally in adults by injecting 
one-quarter of a i per cent, solution subcutaneously along 




-jX-m-ft4/am:?i ^ ^ 



4 

Fig. 165. — Tracheotom}' instruments: i, Blunt retractor; 2, sharp tenaculum, preferably 
grooved on convex side ; 3, 4, sharp and probe-pointed scalpels. 

the line of incision. From 2 drams to J ounce of the solu- 
tion should be necessary to produce local anesthesia. 

Instniniciits Required, — The instruments required are a 
small scalpel, a bistoury, stout angular scissors, dissecting 
forceps, one-half dozen artery clamps, two grooved directors, 
catgut ligatures, tenaculum, two blunt retrators (Fig. 165, l), 
Delaborde's tracheal dilator (Fig. 166), and tracheotomy- 
tubes (Fig. 168). 

Preparation of the Patient. — The patient is placed on the 
table with a small hard pillow, preferably one filled with sand. 



DISEASES OE THE LARYNX 



187 



under his shoulders in such a manner as to brin^^ the trachea 
prominently into view (Fig. 167). However, it is best not 
to adjust the sand-pillow until after the anesthetic has been 



/f 




(I 



Fig. 166. — Delaborde's tracheal dilator. 

given. The skin of the neck is scrubbed with green soap 
and washed with benzene and then with alcohol. Wet 
bichlorid towels are then placed over the chest and scalp 
and under the neck and shoulders. 



|^HH|^^HHHHHHHHH|MH|HH|^H|^ ^ 






^- -. ._M 



Fig. 167. 



-Position of patient tor tracheotomy {Aiiiericai 
Children). 



Text-book of Diseases of 



The High Operation or LaryngotracJieotouiy . — For the 
high operation an incision is made in the median line from 
the top o{ the thyroid cartilage to the second tracheal ring. 



288 DISEASES OE THE NOSE, THROAT, AND EAR 

The handle of the scalpel is used to uncover the cricothy- 
roid membrane (Fig. 132), on which will be seen, extending 
transversely across, the cricothyroid artery and vein. Push- 
ing these to one side a transverse incision is made through 
the membrane and mucous membrane of the larynx. A 
tracheotomy-tube is then inserted. 

This is the simplest and easiest form of the " high opera- 
tion " and is properly called laryngotomy. It is useful in 
cases of imminent suffocation, when there is not time to 
perform a deliberate low tracheotomy. 

In cases where sufficient room is not secured by a trans- 
verse incision of the cricothyroid membrane ImyngotracJie- 
otoniy is necessary. This consists in dividing the cricoid car- 
tilage and the first ring of the trachea. Below this point 
there is danger of wounding the isthmus of the thyroid 
gland and causing profuse hemorrhage. The cricoid and 
first ring of the trachea are divided either by the scissors, 
one blade being inserted within the trachea through the 
incision in the cricothyroid membrane, or the trachea is 
steadied by the tenaculum and a bistoury is inserted in the 
wound and made to cut through the cartilage. In adults 
the cricoid is not infrequently partially ossified, so that a 
somewhat stout pair of scissors is required to sever it. 

TJie Low Operation, — The incision should extend from 
the cricoid cartilage to within I inch of the sternum. When 
the skin is divided the transverse fascia will be brought 
into view. An opening is made in this near the middle of 
the wound by lifting it up with the dissecting forceps and 
incising it sufficiently to permit the introduction of a 
grooved director, which is thrust upward to the upper 
border of the wound. No vessel of any size being visible 
over the director, the fascia is incised. This is repeated in 
the lower half of the wound. The deep fascia uniting the 
two pairs of muscles, the sternohyoid and sternothyroid, is 
now brought into view and is treated in the same manner, but 
care should be exercised in using the knife and grooved 
director that the cuts in the fascia extend completely to each 
angle of the wound to prevent it becoming funnel shaped by 
the time the trachea is reached. 

A layer of areolar tissue and fat is now encountered con- 



DISEASES OF TlfE LARYNX 289 

tainin^^ many cnijor^cd veins. These, if possible, are 
pushed to one side as the operator proceeds with <^rooved 
director and knife to uncover the trachea. If it is impos- 
sible to push a vein to one side, two ligatures are passed 
under it and tied some distance apart, after which the vein 
is cut. 

The wound is now widely opened by means of blunt 
retractors in the hands of an assistant. Its depth, especially 
at the lower extremity, may perhaps appall the inexperienced 
operator, wdio, however, can assure himself that he has not 
"missed the trachea" by tracing its course in the wound 
from above downward with his finger-tip. His fears wall be 
quieted when, after carefully separating the fat and loose 
connective tissue in the median line, the trachea finally is 
uncovered, first at the upper end of the wound, where it 
lies most superficially. In this locality also during the 
operation will probably appear the isthmus of the thyroid 
gland. This should be pulled upward out of the way by an 
assistant or, should that prove impossible, the isthmus can 
be cut between two ligatures. 

The trachea having been reached and the wound dry and 
free from blood, the tenaculum is inserted in it in the 
median line near the upper portion of the wound with the 
point of the tenaculum directed upward. The use of the 
tenaculum is necessary because of the constant movement 
of the trachea. 

The trachea being steadied by the tenaculum, the point 
of a bistoury or scalpel is inserted in the trachea in such 
a manner as to pierce its mucous membrane, but not to 
cut the posterior wall of the trachea. Cutting carefully and 
avoiding long sweeps of the knife, which might endanger 
the posterior wall, three rings are cut, one after the other, 
with a perceptible snap, yielding in an adult an incision 
in the trachea about |- inch in length. The knife is now^ 
withdrawn and Delaborde's tracheal dilator (Fig. 166) in- 
serted and opened, widely separating the edges of the 
tracheal incision. 

The moment the trachea is opened, any blood in the 
wound is sucked into the trachea and immediately violently 
expelled together with any mucus contained in the trachea. 

19 



290 DISEASES OF THE NOSE, THROAT, AND EAR 

The lungs then seem to empty themselves of air and the 
patient stops breathing for a period which may be an 
anxious one to an inexperienced operator. Finally, a long, 
deep breath is taken and from then on the respiration is 
normal. The tracheotomy-tube should now be inserted 
and be secured by tapes (Fig. 168, b). The upper end of 




Fig. i58. — Tracheotomj' 



A, Tracheotom3--tube with pilot; 
tion (Stoney). 



B. tracheotomy- tube in posi- 



the wound is secured by sutures, a portion at least of the 
lower end being allowed to remain open for drainage. A 
rectangular piece of iodoform gauze sufficiently large to 
cover the wound is slit in such a manner that it can be in- 
serted underneath the shield of the tube next the skin, and 
is held in place by the tape. A handkerchief is tied loosely 
about the neck in such a manner that a flap falls down over 
the tube and prevents the entrance of dust and other 
materials, and also receives secretions which are coughed 
out through the tube and immediately sucked back into 
the trachea unless absorbed by the handkerchief or gauze 
and removed by the attendant. In diphtheria cases the 
inner tube should be removed and cleansed by the nurse 
every two hours or oftener should the circumstances require 



J)/SKASI':S Of 77//': LA/<YNX 29 1 

it. When necessary the outer tube should be removed and 
cleansed by the sur<^con. The reintroduction of the tube is 
facilitated by the pilot (Fig. 168, a) or by the use of Dela- 
borde's dilator (Fig. 166), one or both of which should be 
at hand during the after-treatment. 

After tracheotomy, during the time the patient is confined 
to his room, generally a week or two, the air of the room 
should be kept at a temperature of 80° F. and impregnated 
with steam from boiling water. In di[)htheria cases the 
steam aids in keeping the secretions moist and liquid and 
tends to prev^ent the occurrence of tracheotomy bronchitis 
or pneumonia. 

A liquid diet should be maintained for a i^w days after 
the operation. 

The wound above and below the tube usually heals 
rapidly, but exuberant granulations about the tube may 
require removal by scissors or caret. 



THE EAR 



ANATOMY OF THE EAR 

The ear is divided into the external ear, comprising the 
auricle or pinna and the external auditory canal ; the middle 
ear, comprising the membrana tympani, cavity of the 
tympanum, the mastoid cells, and the Eustachian tube ; the 




EustachCtmmdc 
^^__ laid ope 17 

rc/'Ttfmpa, 
Fig. 169. — Front view of the organ of hearing (Randall). 

internal Q?iY or labyrinth, comprising the vestibule, the semi- 
circular canals, the cochlea, and the auditory nerve (Fig. 
169). 

THE EXTERNAL EAR 

The Auricle or Pinna. — The auricle is an irregular mass 
of reticular cartilage deficient at certain parts, where it is 
connected by fibrous tissue and muscles. The cartilage is 
covered by perichondrium, outside of which is firmly ad- 
herent skin, containing sweat and sebaceous glands. 
292 



ANATOMY OF THE EAR 



293 



The names given to the clcvatio)is and depressions of the 
pinna are the heHx, antihehx, fossa of the hehx, fossa of 
the antihehx, tragus, antitragus, concha, and lobule (Fig. 
170). 

Muscles of the Auricle. — Those on the anterior surface 
are the tragicus, the antitragicus, the helix major, and the 
helix minor. Those on the posterior surface are the trans- 
versus auricuLe and the obliquus auricuLe. Those which 
connect the auricle with the side of the head and move the 
pinna as a whole are the attolens, 
attrahens, and retrahens aurem. 

The lobule of the ear is the in- 
ferior, soft, pendulous part of the 
pinna, consisting of fat and con- 
nective tissue covered by skin (Fig, 
170). 

Vessels and Nerves. — The arter- 
ies are the anterior auricular branch 
of the temporal artery ; the pos- 
terior auricular artery, a branch 
of the external carotid ; and the 
auricular branch of the occipital 
artery. Corresponding veins ac- 
company the arteries. The pos- 
terior auricular artery is sometimes cut by the first incision 
in mastoid operations and causes a somewhat profuse hemor- 
rhage, which is readily controlled. 

The nerves are the auricularis magnus, from the cervical 
plexus ; posterior auricular, from the facial nerve ; the 
auricular branch (Arnold's), from the pneumogastric ; the 
auricular temporal, from the inferior maxillary division of 
the fifth nerve ; and branches from the occipitalis major 
and minor. 

The external auditory canal is composed of a cartilag- 
inous and a bony portion. It is about 1} inches in length, 
the cartilaginous portion being about \ inch in length, 
and forming rather less than one-half the canal, which 
extends from the concha to the drum-head. The external 
auditory meatus is lined with a continuation of the skin of 
the auricle, which within the canal contains hair-follicles 




Fig. 170. — Pinna or auricle (Gray). 



294 DISEASES OF THE NOSE, THROAT, AND EAR 

and ceruminous glands. These glands are most numerous 
at the junction of the cartilagmous and bony portions. 
The course of the canal is generally described as that of 
a spiral turned anteriorly inward and downward ; but in 
some individuals the canal is so straight that the drum- 
head may be inspected by simply illuminating the canal by 
reflected light. 

It should be borne in mind that the auditoiy canal is 
narrowest near its central portion, beyond which it again 
expands into a sort of pouch terminating at the drum-head 
— an anatomic construction which adds to the difficulties 
of removing a foreign body should it penetrate beyond the 
narrowest portion of the canal. 

Pressure in front of the tragus usually closes the lumen 
of the canal ; and, owing to this valve-like arrangement, 
the entrance of foreign bodies into the canal is rendered 
more difficult. The striking feature of the cartilaginous 
meatus is the incisurae Santorini, which completely divide 
the cartilage into three half rings, united by fibro-elastic 
tissue. 

THE MIDDLE EAR 

The membrana tympani is a thin, elastic membrane 
stretched obliquely across the fundus of the external audi- 
tory canal in such a manner that its upper and posterior 
portion is most external. It is divided horizontally by the 
anterior and posterior folds into two unequal portions — the 
membrana flaccida or Shrapnell's membrane and the mem- 
brana tensor or membrana vibrans (Fig. 171). 

Slirapiicir s nicinbrane is composed of skin from the 
auditory canal, and of loose cellular tissue, covered by the 
mucous membrane of the tympanum, on its inner surface. 
Bridging a notch in the bony ring, the incisura Rivini, to 
which it is attached, it passes downward in front of the 
attic or upper chamber of the tympanum. Between 
Shrapnell's membrane and the neck of the malleus is a 
pouch or space called " Prussak's space," which sometimes 
becomes distended with pus during attacks of acute catarrh 
of the middle ear. Under such circumstances a puncture 
through Shrapnell's membrane, just above the short process, 



ANA JVM Y OF THE EAR 295 

will evacuate the pus contained in Prussak's space and 
relieve the pain. 

The Dicuibrami vibraiis or membrana tensor is i)carly 
white in color and is polished on its outer surface. It con- 
sists of three layers — a dermic, formed by a continuation of 
the skin of the auditory canal ; a fibrous (membrana pro- 
pria), consisting of fibers radiating from a point near the 
center to the circumference, and circular fibers, which are 
so numerous at the periphery as to form a dense ring 
around the attached margin of the membrana vibrans and 
a mucous layer continuous with the mucous membrane of 
the tympanum. The handle or manubrium of the malleus 
is fixed between the radiating and circular fibers of the 
membrana propria. The outer surface 
of the drum-head faces downward, for- ^-^ , a 

ward, and outward at an angle of 55 ' ^^^:^ 

degress with the axis of the auditory i> ._^^^^^^ ^^ 

canal. Its outer surface is concave, d .x_-_ ^^ ^^ 

From above, the malleus handle may l| ^-j^jj jfej p 

be seen extending downward and some- m'-^^^^77 p 

what backward from a tubercle, its short ^^ik^^ 

process, and endino; near the center of /'"• .171— Outer surface 

, , ., . , . 01 the ri,a:nt membrana t3'm- 

the drum-head at a depression, the pani: a, Membrana flaccida 

1 T-v • 1-r 1 -11 • A -K or Shrapnell's membrane; 

umbo. Durmg life, when lUummated, k. posterior fold; c, short 
the membrana tympani generally pre- ru\Ticuia"tio:;.\"'maiKs 
sents a triangular lis:ht spot or " cone •^f"^'^; "• umbo; g, cone 
01 light, having its apex at the umbo 

and extending downward and forward to the periphery 
(Fig. 171). The mucous membrane of the inner surface 
of the drum-head is folded upon itself as it passes over the 
chorda tympani nerve, so that two pouches are formed, 
opening dowaiward, one in front of and the other behind 
the manubrium (Fig. 172). 

Vessels of the Membrana Tympani. — The dermoid layer 
is supplied with arterioles by the deep auricular branch of 
the internal maxillary artery ; the mucous membrane, by 
the tympanic branches of the internal maxillary, internal 
carotid, and stylomastoid arteries. 

Nerves of the Membrana Tympani. — To the external 
layer are distributed filaments from the superficial branch 



296 DISEASES OF THE NOSE, THROAT, AND EAR 

of the fifth nerve, while the mucous layer is supplied by 
the tympanic plexus. 

The cavity of the tympanum is of irregular shape. It 
measures about \ inch anteroposteriorly, \ inch vertically, 
and \ inch transversely. It is situated in the petrous por- 
tion of the temporal bone above the jugular fossa, having 
the carotid canal in front, the mastoid cells behind, the 
auditory canal externally, and the labyrinth internally. It 
communicates with the pharynx by means of the Eustachian 
tube and with the mastoid antrum by means of the aditus 
ad antrum. The upper portion of the tympanum is called 
the attic or recessus epitympanicus. It extends outward 




Fig. 172. — Outer half of sagittal section of entire left middle ear : o, Anterior and, p, 
posterior pouches of von Troltsch ; op, ostium pharyngeum tubse ; te. Eustachian tube; 
it, isthmus tubae; int, membrana tympani, with the malleus and incus and the chorda 
tympani nerve ; n, attic or recessus epitympanicus ; an, mastoid antrum ; iv, lu, mastoid 
cells. (Politzer.) 



over the auditory meatus, from which it is separated by a 
wedge-shaped mass of bone, sometimes called the shute. 
On the shute lie the head of the malleus and body of the 
incus. The handle of the malleus and long process of the 
incus descend through the narrow opening from the attic 
into the atriiiiii or lower cavit}^ of the tympanum. 

The roof of the tympanum consists of a thin plate of 
bone, the tegnicn tympani, which separates the tympanic 
cavity from the meninges of the brain. The floor of the 
tympanum is narrow and separates the cavity of the tym- 
panum from the jugular fossa beneath. Near the inner 
wall is a small foramen for the passage of Jacobson's nerve. 



ANATOMY OF THE EAR 



297 



The outer wall consists of the nicnibran.i tympani and the 
bony ring into which it is inserted. In this bony ring, the 



// I I.N 



V.N- 




Fig. 173.— Sections through the tympanum parallel to its inner wall ; median aspect 
of the specimens : 77. Horizontal semicircular canal ; H.N', horizontal portion of aquse- 
ductus Fallopii; KA^. vertical portion. In the upper specimen the section is somewhat 
more median than in the lower, in order to open the horizontal semicircular canal and the 
aqujeductus Fallopii. It will be observed that in the lower specimen the tubercle, H, con- 
taining the semicircular canal is more lateral than the hard ridges of bones below it, HN'. 
containing the facial canal. In the upper specimen the stapes is in the oval window, and 
the topography of the inner wall of the tympanum, the aditus, and the mastoid antrum is 
well shown in both specimens. (Author's specimen.) 



anniilus tympanicus, are two small orifices, the iter chordae 
posterius and iter chordae anterius, for the entrance and exit 
of the chorda tympani nerve. Just in front of and above 



298 DISEASES OF THE NOSE, THROAT, AND EAR 

this bony ring is the Glaserian fissure, in which is lodged 
the long process of the malleus, and which also gives 
passage to some tympanic vessels and the anterior ligament 
of the malleus. 

The inner tympanic wall (Fig. 173), which is nearly 
vertical, bulges outward as an eminence, the promontory, 
corresponding to the first turn of the cochlea. Below, pos- 
teriorly, is the niche, at the bottom of which lies the fenestra 
rotunda or " round window," closed by the membrana tym- 
pani secundaria. This membrane is protected by the exter- 
nal wall of the niche, in which it so lies that it is impossible 
to injure it by means of a straight instrument thrust from 
without through the membrana tympani. Above, poste- 
riorly, is the fenestra ovalis or " oval window," closed by the 
foot-plate of the stapes. Above the oval window is the 
eminence of the aquseductus Fallopii, which transmits the 
facial nerv^e. The pyramid is a hollow conic projection con- 
taining the stapedius muscle, whose tendon escapes by an 
opening at its summit. 

In the posterior wall above is the opening into the 
mastoid antrum, the aditiis ad antrum. The anterior wall 
separates the cavity of the tympanum from the carotid 
canal, which lies immediately below 
and in front of it. In the upper por- 
tion of the anterior wall is the orifice 
of the Eustachian tube. Just above 
is the canal for the tensor tympani 
muscle. The Eustachian tube is sepa- 
rated fron the canal for the tensor 
174.— The malleus, tvmpani musclc by a thin bony plate, 

incus, and stapes of left ear: i 7 / • /- • 

A, Malleus; B, incus; C, thc pVOCCSSIlS COClUcariJOliniS. 

^'^P^^' The ossicles are three small bones so 

arranged as to form a movable chain connecting the mem- 
brana tympani with the fenestra ovalis. These three bone- 
lets are the malleus or hammer ; the incus or anvil ; and 
the stapes or stirrup (Fig. 174). 

The iiialleiis is a somewhat irregularly shaped bone, con- 
sisting of an oval head, articulating with the incus ; a neck, 
a short and long process ; and a manubrium or handle, 
imbedded in the membrana tympani. The head and neck 




ANATOMY OF THE EAR 299 

of the malleus, which project into the tympanic cavity, are 
entirely free from the membrana tympani, the surface of the 
head, which articulates with the incus, being directed back- 
ward. The Xow^g and short processes are situated at the 
junction of the neck and handle of the malleus. The short 
process pushes the membrana tympani outward before it and 
is generally plainly visible during life as a tubercle at the 
upper extremity of the malleus handle. The long process 
passes forward into the Glaserian fissure, with the under wall 
of which it unites in adult life. The malleus is held in posi- 
tion within the tympanum by four ligaments — the anterior, 




Fig. 175. — Ligamentous support of ossicles, viewed from above : l-h. Attachment of 
the iigamentum mallei externum ; X-, head of hammer ; ?', body of incus ;y", point of its 
short process ; a, entrance to the Eustachian tube from the tympanum; r, stapes ; d, 
tendon of stapedius muscle : /', tendon of the tensor tympani leaving the cochlear process; 
g~S, chorda tympani, marking the free edge of the folds of mucous membrane bounding 
the pouches; ti, the upper tendinous fibers of the ligamentum mallei anterius, originating 
above the spina tympanica major, m; j, malleo-incudal joint. (Helmholtz.) 

superior, external, and posterior. Of these ligaments the 
anterior is by far the strongest, the posterior and external 
ligaments being, in a mechanical sense, but one ligament, 
to which Helmholtz has given the name " axial ligament of 
the malleus." 

The incus is the middle one of the three ossicles, its 
name being derived from the shape of its upper part. This 
bonelet consists of a body, a short or horizontal process, 
and a long or descending process. The incus is attached 
at the extremity of its horizontal process to the posterior 
tympanic wall by somewhat weak ligaments (Fig. i/S)- 
The long process of the incus curves downward, and at first 



300 DISEASES OF THE NOSE, THROAT, AND EAR 

somewhat outward, toward the auditory meatus, its tip 
bending sharply inward to articulate with the head of the 
stapes by means of the lenticular process. 

The malleo-inciidal joint is a ginglymus or hinge-joint, 
like that of the knee or elbow. The ligaments of the 
malleus are so arranged that the bone performs the part of 
a lever whose fulcrum is just below the short process. The 
manubrium is the long arm of the lever and, consequently, 
all its movements are repeated in an opposite direction by 
the head of the malleus. Each inward movement of the 
membrana tympani and manubrium causes a slight outward 
movement of the head of the malleus. The incus being 
also suspended as a lever, when its upper part moves out- 
ward with the head of the malleus its long process swings 
inward and pushes the stapes before it, so that the foot-plate 
is forced into the oval window. 

The stapes is the smallest bone in the body. It consists 
of a head, articulating with the lenticular process of the 
incus, two branches, or crura, joining the base, which is con- 
nected by ligamentous fibers with the margin of the oval 
window. The stapes (Fig. 174, (7) measures 4 mm. from its 
head to the foot-plate, the latter measuring 2 J mm. in its 
horizontal diameter. The foot-plate of the stapes is some- 
what kidney shaped. When in position its long axis is 
nearly horizontal, with its convex edge looking upward and 
with its concave edge looking downward. A thin membrane, 
the ligamentum obturatorium stapedius, stretches across the 
space between the base and the crura. 

Muscles of the Tympmuim. — The tensor tympani originates 
from the under surface of the petrous bone, the cartilaginous 
Eustachian tube, and its own osseous canal. It is inserted 
into the handle of the malleus near its root. Its action is to 
draw the membrana inward and increase its tension. The 
tensor tympani muscle is supplied by a nerve from the otic 
ganglion. 

The laxator tympani major and minor have already been 
described as anterior and posterior ligaments of the malleus. 
The stapedius muscle originates from the interior of the 
pyramid (Fig. i jG) and is inserted into the head of the stapes. 
Its action is to lift the anterior part of the foot-plate of the 



ANATOMY OF THE EAR 



301 



stapes out of the oval window, thus antagonizing to a certain 
extent the action of the tensor tympani muscle. The stape- 
dius obtains its nerve-supply by a filament of the facial 
nerve. 

Arteries of the Tyinpainnu. — The tympanic branch of the 
internal maxillary enters the Glaserian fissure and is dis- 
tributed to the membrana tympani. The tympanic branch 
of the internal carotid also supplies the membrana tympani. 
The stylomastoid extends from the posterior auricular to 
the back part of the tympanum and mastoid cells. The 
petrosal artery, a branch of the middle meningeal, enters 
the car through the hiatus Fallopii, and a branch from the 
ascending pharyngeal passes up the Eustachian tube. 



Chprda Typif' 




Fig. 176. — Inner wall of tympanic cavity (Gray). 

Nerves of the Tyvipaimni. — The tympanic branch of the 
glossopharyngeal (Jacobson's nerve) supplies the mucous 
membrane of the tympanum and fenestrae. The tympanic 
branch of the facial nerve supplies the stapedius muscle and 
a branch from the otic ganglion supplies the tensor tympani 
muscle. The chorda tympani nerve passes across the 
tympanum between the handle of the malleus and the long 
process of the incus, without branches. It enters the tym- 
panum by the iter chordae posterius and emerges through 
the iter chordae anterius. 

Tlie Tympanic Plexus. — Jacobson's nerve (tympanic branch 
of the glossopharyngeal) divides into three branches, lying 



302 DISEASES OE THE NOSE, THROAT, AND EAR 

in grooves upon the promontory (Fig. 176). One joins the 
carotid plexus ; a second, the greater superficial petrosal 
nerve; and a third, passing upward and forward, finally 
becomes the lesser superficial petrosal nerve. 

The Eustachian tube, which is about i J inches long, passes 
fi'om the middle ear downward, forward, and inward to 
enter the pharynx. It affords communication between the 
air in the pharynx and that contained in the middle ear. 
The outer third consists of bone, commencing at the lower 
part of the anterior tympanic wall, and gradually narrowing 
to terminate at the angle of junction of the petrous and 
squamous portions of the temporal bones. The inner two- 
thirds of the Eustachian tube consist of elastic cartilage and 
fibrous tissue, which unite the inferior portion of a curved 
cartilaginous plate so as to form a tube. The mucous 
membrane Hning the Eustachian tube is a continuation of 
that of the pharynx and is covered with stratified ciliated 
epithelium. 

The jnuscles that dilate the ^ustachiaji tube are the leva- 
tor palati muscle, which, arising from the petrous bone 
and cartilaginous portion of the tube, is inserted into the 
tissues of the soft palate, and the tensor palati, a flattened 
muscle which, arising from the sphenoid bone and the car- 
tilaginous tube, passes as a broad tendon around the hamu- 
lar process to form the broad aponeurosis of the soft palate. 
The action of both these muscles is to dilate the tube. 
Some of the fibers of the tensor tympani and tensor palati 
are blended, and an aponeurotic connection always exists 
along the Eustachian tube, so that probably these two 
muscles have no action entirely independent of each other. 
When the soft palate is drawn upward the membrane is also 
retracted by the tensor tympani and the Eustachian tube is 
at the same time dilated, so that, although a current of air 
enters the tympanum, it is prevented from forcing the mem- 
brane too far outward and interfering with the equilibrium 
of auditory tension. The tensor tympani . and tensor 
palati receive nerve-filaments from the otic ganglion, but 
the levator palati is supplied by a branch from Meckel's 
ganglion. 

The Eustachian tube receives its arterial supply by the 



ANATOMY OF TJIK EAR 303 

following arteries : The ascending pliaryngeal, branches 
from the middle meningeal and internal maxillary, and a 
branch from the stylomastoid artery. 

Its nerves are, in addition to those supplying muscles of 
the tube, derived from the fifth and seventh pair and the 
glossopharyngeal. 

The Mastoid Process of the Temporal Bone. — At birth the 
mastoid process consists of a small flattened tuberosity con- 
taining but one cell and that of considerable size — the vias- 
toid iDitnnii. At puberty the mastoid process has become 
a distinct prominence, conic in shape, with its apex down- 
ward. The substance of the mastoid process consists of 
small cavities varying greatly in number, size, and shape in 
different individuals. Some of them communicate with each 
other and are lined with a continuation of the mucous 
membrane of the tympanum, which is here covered by 
squamous epithelium. 

THE INTERNAL EAR OR LABYRINTH 

Osseous Boundaries. — At all points the various channels 
and cavities of the labyrinth are deeply imbedded in the 
petrous portion of the temporal bone. The bony labyrinth 
consists of a central cavity, called the *' vestibule," from the 
walls of which spring, like arches, the semicircular canals, 
while through the anterior wall of the vestibule a canal leads 
into the snail-shaped cavity of the cochlea (Fig, 177). 

Contents of the Osseous Labyrinth. — The vestibule contains 
fluid and two distinct membranous sacs, the utricle and 
saccule (Fig. 178). The saccule communicates with one of 
the membranous tubes of the cochlea, the ductus cochlearis, 
by means of a slender membranous tube, the canalis reuniens, 
while the cavity of the utricle is continuous with that of the 
membranous semicircular canals, so that the membranous 
labyrinth may be said to consist of a system of cavities with 
membranous walls containing a fluid, the endolymph, and 
nearly surrounded by another fluid, the perilymph. 

A diaphragm, consisting partly of bone (lamina spiralis 
ossea) and partly of membrane (membranabasilaris), divides 
the cavity of the cochlea into an upper and low^er space of 



304 DISEASES OF THE NOSE, THROAT, AND EAR 



nearly equal size (Fig. 179). The upper, the scala ves- 
tibuli, communicates with the cavity of the vestibule, and 

the lower, the scala tympani, 
ends abruptly at the round 
window. The upper space 
(scala vestibuli) is divided by 
a diaphragm (Reissner's mem- 
brane) placed at an angle of 
45 degrees with the membrana 
basilaris, into the scala vestibuli 
proper and the scala media or 
ductus cochlearis, which, as 
already described (Fig. 178), 
communicates with the sac- 
cule by means of the canalis 
reuniens. The scala media 
or ductus cochlearis contains 
endolymph and the organ of 
Corti (Fig. 180). 
The organ of Corti rests upon the membrana basilaris 
about midway between the lamina spiralis ossea and the 




10 

Fig. 177. — The bony labyrinth laid 
open : I, Recessus ellipticus for utricle ; 
2, recessus sphaericus for saccule ; 3, re- 
cessus cochlea ; 4, pyramis vestibuli ; 5, 
round window ; 6, posterior semicircular 
canal ; 7, external semicircular canal ; 
8, cupola of the cochlea; 9. superior 
semicircular canal ; 10, lamina spiralis 
ossea projecting from the modiolus into 
the calibre of the canal of the cochlea, 
and terminating in the cupola as a hook- 
like process called the " hamulus." 



Auditory ner\'e 
with its vestibu- 
lar and cochlear 
branches. 



Ant. semicircular canal. 
Ampulla. 




Canalis reuniens. Ductus Ampulla, 

endolymphaticus. 



Fig. 178. — Membranous labyrinth of the right ear from five-months'-old human embryo 
(from Schwalbe, after Retzius). 

outer wail of the ductus cochlearis. It extends from the 
vestibule to the cupola of the cochlea, and to it are distrib- 



ANATOMY OF THE EAR 



3<^5 



uted nerve-fibers from the cochlear branch of the auditory- 
nerve. Corti's or<jan is made up of a nearly central arch, 




Fig. 179. — Longitudinal section of the cochlea, showing the relations of the scalae, the 
ganglion spirale, etc. ; S. V, Scala vestibuli ; ^. T, scala tympani ; S.M, scala media ; L.S, 
ligamentum spirale ; G.S, ganglion spirale. (Gray.) 

formed by the inner and outer rods or pillars of Corti (Fig-. 
180), the bases of which are farther apart as the organ of 
Corti ascends from the vestibule to the cupola. There are 




Fig. 180. — Transverse vertical section of Corti's organ of a man twenty-nine years old : 
^j, Limbus laminae spiralis ; wr, membrana tectoria ; ///^, Hensen's striae; ?;{/", fibers of 
attachment of the membrana tectoria to the zona tecta ; si, sulcus spiralis; siz, epithelium 
of the sulcus spiralis ; is, inner supporting ceils ; ic , inner rod cells in connection with the 
outer rod cells, between which is seen the tunnel (t) of Corti ; ///, inner hair-cell ; nh'^-iih^, 
outer hair-cells; dz, Deiters' cells; iis, Hensen's supporting cells; rl>, nerve-fibers of the 
ramulus basilaris ; ii^->fi, outer bundles of the spiral nerve-fibers ; rf, radiating tunnel 
fibers ; at, inner part of Nuel's space ; ;;//>, upper layer of the membrana basilaris ; ;«//, 
lower layer of the membrana basilaris ; tf', layer covering the tympanic surface of the 
membrana basilaris ; iis, ligamentum spirale. (Gruber, after Retzius.) 



at the outside of the arch four rows of ciliated cells and at 
the inner side one row, which receive terminal filaments 
from the cochlear branch of the auditory nerve. The 
20 



306 DISEASES OF THE NOSE, THROAT, AND EAR 

name " hearing cells " is sometimes applied to these hair- 
cells. There is a peculiar fenestrated membrane, the lamina 
reticularis, into whose net-like structure project the cilia of 
the outer hearing cells, which are covered and protected by 
a glue-like substance, the membrana tectoria. The rods of 
Corti have been estimated at about 10,500, while the num- 
ber of hair-cells is estimated to be about 21,300. 

The membranous semicircular canals occupy scarcely one- 
third of the space inside the bony canals, except at the 
ampullae, where they hug the bony walls more closely. 
The space between the membranous canals and the bony 
wall is occupied by connective tissue rich in blood-vessels 
rather than with free fluid, as in the cochlea (Fig. 181). 

The otoliths are granular, amorphous, sometimes crystal- 
line particles found along the walls of the utricle, sac- 
cule, ampullae, membranous canals, on the periosteum of 
the osseous semicircular canals, and in the fluid of the 
cochlea. They consist of about 75 per cent, mineral 
matter, mostly carbonate of lime, and organic material re- 
sembling mucus in its physical and chemic characteristics. 
The function of the otoliths has not been determined, but 
it has been suggested that they exert a damping action 
upon the vibrations of the terminal fibers of the hair-cells. 
In some of the lower animals they are huge in size com- 
pared with those of man and assume fantastic shapes. 

The auditory nerve originates by three fasciculae from the 
superior vermiformis process of the cerebellum and from 
the inner and outer nuclei, formed chiefly by the gray sub- 
stance of the posterior p^^ramid and restiform body. The 
nerve emerges, superficially, from a groove between the 
olivary and restiform bodies at the lower border of the 
pons. At the bottom of the internal auditory canal it 
divides into the cochlear and vestibular divisions, both of 
which contain ganghon cells. The cochlear nerve divides 
into numerous filaments to enter the modiolus and sends 
branches to each of the hair-cells (Fig. 180). The vestib- 
ular nerve divides into three branches : The filaments from 
the upper branch enter the vestibule through the macula 
cribrosa at the bottom of the internal meatus, and are dis- 
tributed to the utricle and the ampulla of the external and 



ANATOMY OF THE EAR 



307 




superior semicircular canals; the niicklle branch is distributed 
to the saccule, and the inferior branch passes to tlie ampulla 
of the posterior semicircular 
canals. 

Function of the Semicircular 
Canals. — They appear to be a 
peripheral space-organ, and 
through centers in the brain 
regulate the movements of the 
muscles of the eye and probably 
all the muscles of the body for 
the preservation of equilibrium. 
The power of maintaining equi- 
librium is derived from the edu- 
cation of touch and sight and 
information derived from the 
peripheral space-organ within 
the ear, which informs the brain 
of the position of the head and 
regulates the movements of 
the muscles for the preserva- 
tion of equilibrium. If pres- 
sure be made upon the membrane of the round window, 
dizziness and an inclination to fall backward are produced 
as the result of the pressure transmitted to the ampulla of 
the posterior canal. If the foot-plate of the stapes be 
pressed upon, a rocking sensation of the head from side to 
side will be felt, indicative of the transference of the pres- 
sure to the ampulla of the superior canal. It is impossible 
to transmit pressure to the fluid of the horizontal canal, 
and when strong pressure is made upon the fluid within 
the vestibule there is produced dizziness without sensation 
of falling in any especial direction. 

Functions of the Vestibule and Cochlea. — Except that in a 
general way the vestibule and cochlea have to do with the 
sense of hearing, the functions of these parts of the ear are 
not clearly understood. It is supposed that the individual 
hair-cells and rods of Corti vibrate to single tones, and that 
a compound sound causes the vibration of a number of hair- 
cells proportionate to its composite character. 



Fig. 181. — Section through the osseous 
and membranous semicircuhir canals : 
a. Osseous semicircular canal ; /■, place 
of attachment of the membranous semi- 
circular canal ; c. elevations on the inner 
surface of the membranous semicircular 
canal ; d, vascular bands of connective 
tissue. (Politzer.) 



3o8 DISEASES OF THE NOSE, THROAT, AND EAR 

TESTS FOR HEARING 

Hearing is the faculty of the perception of sound. 

Sound is a pecuHar sensation excited in the organs of 
hearing by the vibratory motion of bodies, the effects of 
which are transmitted to the ear through an elastic medium. 

Sound is a sensation and should be distinguished carefully 
from the vibrations that produce it ; which vibrations, of 
course, may exist without the presence of an organized being 
to perceive them. 

Sources of Sotuid. — Sound is produced by the rapid vibra- 
tions that take place in the molecules of bodies when they 
are disturbed by shock or by friction. When a resonant 
body is struck its molecules alternately approach and recede 
from one another with a velocity and amphtude of vibrations 
corresponding to the form, size, and molecular composition 
of the body ; and this motion is transmitted by contact to 
any surrounding elastic medium, such as air. Sound-waves 
so produced are in part reflected in passing from a rarer to 
a denser medium, as, for example, when passing from air 
into water. If, however, a tense membrane, free to vibrate, 
is interposed between the air and any fluid or solid medium, 
the aerial vibrations are not reflected, but are transmitted 
into the more solid medium with little loss of their intensity. 
But for the membranes of the middle ear, sound-waves trans- 
mitted from the ear to the lymph of the labyrinth would 
lose intensity to such a degree as to be inaudible. 

Acoustics is that department of physics which treats of 
sounds. A rudimentary knowledge of the laws of acoustics 
is essential to an understanding of the physiology of the ear. 

The science of music treats of a peculiar class of sounds 
and combination of sounds calculated to produce pleasur- 
able emotions. Such sounds are distinguished from noises, 
which are sounds either of very short duration, like the re- 
ports of firearms, or are a mixture of many discordant 
sounds. 

Pcndiiltun Vibration. — If a needle be attached to one arm 
of a vibrating tuning-fork, and if in contact with the end of 
the needle a piece of smoked paper be moved at a uniform 
velocity, a tracing of the vibrations of the needle will be 



TESTS FOR IIKARLXC 3O9 

scratched upon the paper (Fig. 182). This tracin^^ is a 
record of the miviber of vibrations of tlie fork during a given 
time and of the aniplitiidc of the vibrations. The record is 
regular and uniform, and so simihir to that produced by a 
pendulum under similar circumstances that Huxley has de- 
scribed this form of vibration under the name of poidiiluin 
vibration. 

A tone is a sound produced by a simple pendulum vibra- 
tion. It has the characteristics of quality or *' timbre " ; in- 
tensity, volume or loudness ; and pitch (high or low tone). 

The quality of a tone depends largely upon the material 
of the substance which produces the tone. The quality of 
the note emitted by striking a strip of wood is entirely dif- 
ferent as regards its quality or " timbre " from that produced 
by striking a rod of metal. A note produced from an organ, 
a violin, and a cornet may in each case have the same pitch 



r^r>i\r\rv/vvsrvNrv/Nf\r\rvrN/\rs 



Fig. 182. — Tracing on smoked paper produced by the vibrations of a tuning-fork. 

and volume, but will differ widely from one another as re- 
gards quality or timbre. 

The intensity of a tone depends upon the force and ampli- 
tude of the vibrations which produce it. When a tuning- 
fork is first made to vibrate, its tone is comparatively intense 
or loud, because the force and amplitude of its vibrations 
are comparatively great, but as it continues to vibrate its 
tone is heard less and less distinctly, because the force and 
amplitude of its vibrations are becoming less and less. The 
pitch of the tone, however, remains the same until the fork 
ceases to vibrate. 

The pitcli of a tone depends upon the rapidity of the vi- 
brations that produce it. The more rapid the vibrations, 
the higher the pitch. The human ear is generally able to 
distinguish the tone produced by a tuning-fork vibrating 
only 16 times during a second, and also that of a fork vi- 
brating 38,000 times a second. The capacity, however, to 



310 DISEASES OF THE NOSE, THROAT, AND EAR 

distinguish sounds of very low or very high pitch varies 
greatly in individuals, but the ears of most persons are more 
sensitive to sounds of low than to those of high pitch. 
Prof Tyndall says :. " The squawk of the bat, the sound of 
the cricket, even the chirp of the common house-sparrow, 
are unheard by some persons who for lower sounds possess 
a sensitive ear." 

The inability to hear high notes increases with age, and 
generally also as the result of disease of the labyrinth or 
acoustic nerve ; and in testing the acuteness of hearing by 
means of tuning-forks and Galton's whistle it is well to bear 
this fact in mind. For careful tests as to the sensitiveness 
of the perceptive apparatus it is well for the aurist to be 
provided with at least five forks, the lowest (c-2) giving 32 




Fig-. 183.— Galton's whistle with rubber bulb. The pipe below the opening is filled by 
a plunger advanced or withdrawn by a screw, each turn being shown by the scale upon 
the enlarged tube, and its tenths by that on the revolving collar. It gives an audible 
sound from 0.5 (theoretically, 84,000 v. s) to 10 or 12 (4200 or 3500). 

vibrations during a second and the highest (cj yielding 2048 
vibrations in a second. Galton's whistle (Fig. 183) and 
Konig's rods will be found useful also for making tests of 
this kind. Konig's rods are ten steel cylinders, 20 mm. in 
diameter, suspended by cords attached to them at a distance 
from each end of one-fifth of the length of each rod. The 
rods are of such a length that when struck with a hammer 
they produce tones, the lowest of which give 4096, and the 
highest 32,768, vibrations per second. 

Galtoji's zvliistlc for testing the higher tones of the scale 
is more convenient than Konig's rods. It consists of a 
metal tabe so perforated as to cause a whistle when air is 
blown through it by means of a rubber bulb attached to the 
proximal extremity of the instrument. The distal extremity 
is closed by a metal rod capable of being moved backward 



TESTS FOR IIEARIXG 



311 



and forward within the tube by a micrometer screw. The 
length of the column of air within the tube beyond the per- 
foration, and consec^uently the pitcli of the note emitted by 
the w^histle, are determined by the position of tlie rod within 
the tube. The micrometer screw is graduated to indicate 
single numbers, while on the side of the tube is a scale to 
show tens ; so that by turning the micrometer screw the 
metal rod within the hollow cylinder can be placed in any 
position indicated by a number on a scale having a range of 
from I to 120. The following table indicates the number of 
vibrations per second of the note emitted by the whistle 
corresponding with the numbers on its scale : 



Vibration per second 
Scale 


84000 
10 


56000 
15 


42000 
20 


33600 
25 


2 8c 00 
30 


24000 
35 


21000 
40 


18666 
45 


Vibration per second 
Scale 


16800 
50 


15273 
55 


14000 
60 


12933 
65 


12000 
70 


1 1200 
75 


■°r 


gSac 
85 


Vibration per second 
Scale 


9330 
90 


8842 
95 


8400 
100 


8000 
105 


7591 
110 


7305 
115 


7000 
120 





Helmholtz states that the human ear is able to distinguish 
as musical notes tones lying betw^ecn 16 and 38,000 vibra- 
tions per second, or a range of about 1 1 octaves, but that 
the lowest note used in orchestral music is e-^ or one of 40 
vibrations per second. In pianos the lowest note in general 
use is c-,„ 32 vibrations per second ; and the highest, 7 octaves 
above it, is c^, 4096 vibrations during a second. The fol- 
lowing table is from Appun : 



C-'=32 


D-»=36 


E-2=4o 


F-=42.es 


0-2=48 


A-==53,35 


H-2=6o 


C-^=64 


D-i = 72 


E-i=8o 


F-' =85.33 


0-1=96 


A-i = io6,66 


H-» = I20 


c =128 


d =144 


e =160 


f =170,66 


g =192 


a =213,33 


h =240 


0^=256 


di -=288 


e*=32o 


f'=34i.32 


g'=3S4 


al=420,66 


hi =480 


C»=5I2 


d= =576 


e==64o 


f==682.e. 


g= = 768 


a===853.32 


h2=96o 


C 3 =^1024 


d^ =1152 


e3=i28o 


<^=i365.28 


g3=i536 


a3 = 1706,64 


h3=I920 


c*=2048 


d* =2304 


e*=256o 


f*=27IO,36 


g4=3072 


a*=34i3.29 


h*=384o 


c»=4096 


ds =4608 


e==5i2o 


P = 542I.,2 


g«=6i44 


a^=6826,5e 


h-'^=768o 


c8u=8i92 


d6 =9216 


6^ = 10240 


f6=I0842,34 


g6 =12288 


3^=13653.12 


h6 = i536o 


0^=16384 


d^ =18432 


e'' =20480 


f-=2i684.^8 


g7 = 24576 


a^=273o6.24 


h" =30720 



Hannoiiy. — If the rates of vibration in a second of two 
notes simultaneously produced stand to each other in the 
ratio of simple multiples, so that while the low note makes 
I vibration the high note makes 2, 3, 4, etc., the notes are 
said to be in harmony or concord, and the result is con- 
sonance. These are the ratios of the human voice in 
ordinary speaking or singing, and, accordnig to Wolf, 



312 DISEASES OF THE NOSE, THROAT, AND EAR 

speech has a compass of 5 octaves, from c to c^. The 
simplest ratio is \, and to this the name octave is given. In 
this case the higher note has double the number of vibra- 
tions of the lower. The ratio of the notes in the diatonic 
major scale is as follows: 

C. 



D. 


E. 


F. 


G. 


A. 


B. 


c 


f 


f 


* 


1 


f 


¥ 


4 



The timing-fork used to test the hearing should be large 
enough to secure sufficient intensity or loudness of tone. 
It is not absolutely necessary, but desirable, to have the 




tuning-fork provided with movable clamps, so as to deaden 
overtones. While it is more convenient, as stated, for the 
aurist to be provided with at least five forks of different 
pitch, yet one sounding the note Cj (512 vibrations per 
second) will generally answer the purpose of ordinary 



TJ':S'J\S FOR HEARING 



313 



clinical investigations. It is convenient to have at hand a 
small tuning-fork emitting a tone of feeble intensity (Fig. 
185), in order to confine the sound to one ear; because 
when a very heavy tuning-fork is employed in examining 
patients whose hearing is greatly impaired only in one ear, 
it is impossible to be certain that the sound of a large fork 
is not heard by the ear in which the hearing is better. 
When the fork is used for testing the hearing 
of the ear in which the hearing is more de- 
ficient, a large fork, provided with movable 
clamps, can, however, generally be made to 
answer the same purpose by placing the 
clamps sufficiently low dowai upon the tines 
of the instrument. 

Weber's Test. — E. H. Weber demonstrated 
that w^hen a vibrating tuning-fork is placed 
against the teeth or on a point of the cranium 
the tone is heard better by a person with 
normal hearing if the ears are closed by the 
fingers. If only one ear is closed, the fork 
is heard best in that ear. Weber, Rinne, and 
Toynbee attributed this phenomenon to in- 
creased resonance ; Mach, to the obstruction 
of the outlet of sound-waves through the 
auditory canal. Probably each of these factors should be 
given due weight as a cause of the phenomenon. 

It should be borne in mind that any obstruction to 
the exit of sound-waves from the middle ear when a tuning- 



FiG. 185. — Small 
tuning-fork. 



is vibrating with its handle in contact with the teeth 



fork 

or at a point upon the cranium midway between each ear, 
will cause the sound of the fork to be heard most distinctly 
in the obstructed ear. The cause of obstruction may be 
impacted cerumen in the external auditory meatus, occlu- 
sion of the Eustachian tube, mucus within the tympanum, 
or thickening of the membrana tympani as the result of 
catarrh of the middle ear. Hence, if a patient is deaf in only 
one ear from any of these causes, a vibrating tuning-fork, 
with its handle in contact with the teeth or on a point on 
the cranium midway between the ears, will be heard by him 
better in the deaf ear. If, how^ever, the hardness of hearing 



314 DISEASES OF THE NOSE, THROAT, AND EAR 

is due to impairment of the labyrinth or of the auditory 
nerve, the note of the tuning-fork will be heard less dis- 
tinctly ill the deaf ear. 

In practising Weber's method of examining the hearing, 
the observer should bear in mind that the answers of some 
patients will largely be determined by their imagination, and 
that they at first will say that they hear the sound of the 
fork most distinctly in that ear in which the hearing is better, 
simply because tliey think they sJioidd do so. The test should 
be repeated sufficiently often to convince the observer that 
his patient's answers are rehable. It will, in all instances, 
be judicious to request the patient, while the fork is still 
vibrating upon the cranium, to close first one ear and then 
the other with a finger, and only after this has been done to 
ask him in which ear he now hears the sound of the fork 
most distinctly. 

Rinne's Test. — Rinne observed that when a vibrating tun- 
ing-fork, with its handle in contact with the tissues over the 
mastoid process, ceased to be heard, the sound of the fork 
reappeared if it was held in front of the ear. Aerial con- 
duction is superior to tissue-conduction in individuals with 
normal ears. If the tuning-fork is heard best by aerial con- 
duction, the fact may be noted as Rinne+ ; or Rinne— if 
the contrary is the case ; or, to be more exact, the number 
of seconds that the tuning-fork is heard upon the mastoid 
and in front of the auditory meatus may be given in the 
form of a fraction, the numerator of which will be less than 
the denominator if Rinne's method yields a positive result, 
and the contrary will be the case if Rinne's method gives a 
negative result. Thus, if the note of a Cg tuning-fork 
whose handle is in contact with the mastoid process is heard 
for twenty seconds, and for fifty seconds when its tines are 
held close to the external auditory meatus, the fact may be 
noted thus : Rinne + ||. If, however, the fork is heard for 
thirty seconds when its handle is in contact with the tissues 
over the mastoid process, and only ten seconds when its 
prongs are held close to the meatus, the fact should be 
noted as Rinne — f ^ (R. — |^). In the first instance any 
hardness of hearing is due to impairment of the nervous 
part of the ear ; in the latter case it is due to the result of 



TESTS FOR HEARING 315 

disease or to imperfection of the external or middle ear, or 
both. 

It is a well-known fact that any rii^idity of the conducting 
apparatus so alters the relation of tissue to aerial conduction 
that the former finally exceeds the latter. This change 
begins with the low notes. If Rinne's method be employed 
on a patient in whom there is only a slight impairment of the 
patency of the Eustachian tubes, with congestion of the 
mucous membrane of the tympanum, the result will be nega- 
tive with forks emitting a very low-pitched note and positive 
for that of a higher pitch. That is, the sound of the fork of 
low pitch will be heard louder and longer when its handle is 
firmly pressed upon the mastoid process than when the tines 
of the fork are held in front of the meatus. This, however, 
will not be the case if a fork emitting a high-pitched tone be 
employed. In conditions in which there is great rigidity of 
the transmitting apparatus of the ear, the receptive apparatus 
remaining healthy, Rinne's test will yield a negativ^e result 
with forks of high as well as low pitch. Generally under 
such circumstances tissue-conduction will be apparently in- 
creased ; that is, a tuning-fork with its handle pressed upon 
the tissues ov^er the mastoid will be heard louder and longer 
than normal. When, instead of this being the case, tissue- 
conduction as well as aerial conduction is decreased, impair- 
ment of the functions of the internal ear should be suspected, 
although it should be borne in mind, when testing the hearing 
of patients past middle life, that tissue-conduction of sound is 
always decreased as the result of senility, and sometimes as 
the result of other causes besides disease of the internal ear. 

In any case, however, in which the acuteness of hearing 
is reduced to the perception of words spoken in a loud voice 
close to the ear, if tissue-conduction is greater than aerial 
conduction only for forks of low pitch (C^ to c) while those 
of high pitch (c.^, cj are heard very imperfectly, if at all, 
either by aerial or tissue-conduction, the receptiv^e apparatus, 
as well as the middle ear, is impaired. In such cases, 
although the tension of the structures of the middle ear can 
doubtless be removed by operative procedures, the perform- 
ing of such an operation will not result in a great improve- 
ment in the patient's hearing. 



3l6 DISEASES OF THE NOSE, THROAT, AND EAR 

Schwabach's Test. — This test consists in comparing the 
number of seconds a tuning-fork is heard on the mastoid 
and at the meatus in a normal ear with the time the fork is 
heard in these positions by the ear being examined. 

Gelle's Test (Pressions Centripetes). — If the air within the 
auditory canal be compressed by means of Siegle's speculum 
or any suitable instrument, a normal ear wall hear the sound 
of a tuning-fork vibrating on the cranial bones with dimin- 
ished intensity. This phenomenon is due to increased laby- 
rinthine pressure, because when the air within the auditory 
canal is condensed the chain of bonelets with the foot-plate 
of the stapes is pressed inward. If ankylosis of the stapes 
exists or if there is great immobility of the ossicles the tone 
of the tuning-fork will remain unchanged during the test, 
while if the labyrinth is diseased and the stapes is movable 
the application of Gelle's test will produce dizziness. 

Bing's Test. — If a tuning-fork is vibrated upon the mastoid 
process of a normal ear, after its sound is no longer audible 
it can be made to reappear if the meatus is tightly closed 
with the moistened finger. In cases of severe deafness, 
according to Bing, if this test yields a negative result, the 
hardness of hearing is due to a middle-ear affection, while 
if the result of the test is positive, the deafness is the con- 
sequence of a labyrinthine affection. 

Dr. Bing uses also, as an aid to diagnosis, what he terms 
the " entotic " use of the speaking-trumpet, which consists 
in speaking into a speaking-tube connected by means of an 
air-tight joint with a catheter introduced into the mouth of 
the Eustachian tube. If the voice is heard better by this 
method than when the speaking-tube is used in the external 
meatus, there is hindrance to sound-conduction at the mal- 
leus or the incus, and the foot-plate of the stapes is freely 
movable in the oval window. 

To test the hearing by a watch the patient should be seated 
with his face so covered by a napkin or towel that it is 
impossible for him to see the watch, because many patients 
imagine that they hear a watch which they see held close to 
their ear. It is well also to request the patient to close firmly 
with his forefinger the ear that is not being tested. The aurist 
should hold the watch in his hand with its case open close 



7'ESTS FOR HEARING 317 

to the patient's ear until tlie latter hears it distinctly, then 
move his hand to a considerable distance and slowly bring 
the watch tow^ard the ear being examined, observing the 
exact distance the watch iswhen^r^Y heard. The result of 
the examination may be expressed by a fraction, the numer- 
ator of which is the distance at which the patient hears the 
watch and the denominator the distance at which the watch 
can be heard by a normal ear. For example, if the watch 
used in making the test is heard by a normal ear at 40 
inches, and the patient hears it only at 15 inches, the fact 
may be recorded thus : Hearing for watch is if (H. W.-== l|). 
If the watch is heard only on contact with the auricle, the 
record should read, Hearing for watch is ^J^ ; or, if it is 
only heard by exerting considerable pressure with it upon 
the auricle, Hearincf for watch is E!!!^^. 

The room in which the hearing is being tested by the 
watch should be as free from noise as possible, and the 
watch should invariably be made to approach the patient's 
ear from a distance as directed above, and the point be noted 
at which it is first heard, because, while the patient still hears 
the watch if it is slowly carried away from his ear, it will be 
found that he will continue to hear it at a much greater dis- 
tance than that at which he would first hear it if it were 
made to approach his ear from a distance. The hearing 
may be tested in a similar manner by means of the acoumeter, 
an instrument devised by Politzer. The acoumeter gives the 
note c with about the same loudness as the sound of a 
loud-ticking watch. 

In testing the hearing by the voice the patient should close 
the ear not being tested firmly with his forefinger, and either 
close his eyes or look in such a direction that it will be impos- 
sible to see the motion of the aurist's hps ; the distance in 
feet should then be observed at which words are heard 
when spoken in a whisper, ordinary conversational tone, or 
a loud voice if the patient be very deaf In making this test 
of the hearing-power it is best, in most instances, to employ 
single words of only one syllable. The result of the exam- 
ination may be noted as a fraction, the numerator of which 
is the distance in feet at which the patient hears the words 



3l8 DISEASES OF THE NOSE, THROAT, AND. EAR 

and the denominator the distance in feet at which a normal 
ear can hear the same words. For example, if the patient 
hears whispered words 3 feet from his ear, and should hear 
them at 10 feet, the fact may be recorded thus : Whisper j^^. 

PATHOLOGIC CONDITIONS OF NOSE AND 
PHARYNX CAUSING DISEASE OF EAR 

As the result of long-continued chronic nasopharyngeal 
catarrh the Eustachian tubes and middle ear become affected 
in a proportion of cases. Especially if the catarrh be of 
the hypertrophic variety, so that nasal respiration is inter- 
fered with by the presence of anterior and posterior hyper- 
trophies, ecchondroses or exostoses from the septum, etc., 
is disease of the Eustachian tubes prone to result. The 
same is true of a deflection of the septum sufficiently great 
to cause marked obstruction of one nostril. In many 
instances catarrh of the Eustachian tube and middle ear is 
the result of the extension by continuity of surface of a 
similar affection of the nasopharynx. However, when one or 
both nasal chambers are obstructed other causes probably 
bring about the same result. Posterior to the obstruction, 
in nearly all cases of nasal stenosis, a partial vacuum is 
formed during inspiration ; as the result, the nasal mucous 
membrane is constantly engorged with blood in this locality. 
This condition may extend back far enough to involve the 
phar^mgeal mouth of the Eustachian tube. Probably most 
cases of one-sided deafness on the same side as an obstructed 
nostril may be explained in this manner. The hearing in 
such cases frequently improves rapidly after the removal of 
the nasal stenosis, but a posterior hypertrophy may be so 
situated as to produce venous stasis in that locality. By 
far the commonest cause of Eustachian salpingitis, in chil- 
dren at least, is hypertrophy of the pharyngeal tonsil. When 
the adenoid overgrowth is situated so as to interfere with the 
return of blood from the mucous membrane of the 
Eustachian tubes, stenosis results because of engorgement 
and inflammation, and the hearing deteriorates more and 
more as the result of each succeeding attack of coryza. 
Under such circumstances, if the hypertrophy has not 



NASAL CONDITIONS CAUSING DISEASE OE EAN 319 

existed too Ioiil;', a complete restoration of the liearini; may 
be expected to follow the removal of a portion of the 
hypertrophied gland. However, it must not be supposed 
that by removing the nasal disease which produced the 
aural affection a complete restoration of the hearing will 
result in every instance. In most cases of this kind careful 
treatment of the tubal or middle-ear disease is absolutely 
necessary. 

The pharyngeal mouths of the Eustachian tubes, bordered 
by their cartilaginous lips, appear as crater-shaped eleva- 
tions in front of Rosenmiiller's fossa. The mucous mem- 
brane at the entrance of the tube is, in the normal state, 
paler than that in its vicinity, which is of a deep-red color 
over the cartilaginous lips. In atrophy of the tube-mouths 
the mucous membrane covering the lips of the tube is pale 
in color and the parts appear shrunken. In catarrh of the 
Eustachian tube the mouth of the tube will sometimes 
appear dilated by a mass of mucus exuding from it, and 
under such circumstances the tube-mouth is generally 
greatly swollen. 

Patency of Eustachian Tubes. — The methods most com- 
monly used to test the patency of the Eustachian tubes 
and introduce air into the middle ear are Valsalva's, PoHt- 
zer's, and catheterization of the Eustachian tubes. 

Valsalva's inetJiod consists in a forced expiration, the 
mouth and nose being closed. In this method air is forced 
from the pharynx through the Eustachian tubes into the 
middle ear. If the aurist examines the membrana tympani 
while the patient inflates the middle ear by Valsalva's 
method the drum-head will be observed to move outward, 
and in most instances it will become slightly congested. 
If an aural stethoscope be used a slight noise will be heard 
as the air enters the patient's middle ear. 

The aural stethoscope or aiisc2iltation-tiibe consists of about 
3 feet of thin rubber tubing into the ends of which appro- 
priate ear-pieces are inserted. One ear-piece should be of 
white bone for the aurist's own ear, and the other end of 
hard rubber, to be inserted into the auditory canals of his 
patient's ears. In using the aural stethoscope for the 
auscultation of the right ear of a patient the aurist should 



320 DISEASES OF THE NOSE, THROAT, AND EAR 

first insert the white end-piece into his own right ear= The 
patient is then instructed to place the hard-rubber ear-piece 
loosely in his ear and hold it in position with his thumb 
and finger. 

In Poliizer's method the patient is directed to hold a 
small quantity of water in his mouth until he is told to 
swallow. The aurist then takes the nose-piece of Politzer's 
air-bag (Fig. 187) between his thumb and finger and inserts 
it into one of the patient's nostrils, and closes both nostrils 
firmly about the nose-piece by pressure with his middle 
finger and forefinger. The patient is then told to swallow ; 
as the patient's larynx is seen to rise at the commencement of 
the act of swallowing the aurist quickly compresses the air- 




FiG. 186. — Toynbee's auscultation-tube. 

bag held in his right hand, thus forcing air through the nose 
and Eustachian tubes into the middle ear. If the auscul- 
tation-tube is used during this procedure, the air will be 
heard to enter the middle ear with the same audible click 
observed when Valsalva's method of inflating the middle 
ear is employed. 

During the act of swallowing the soft palate rises, thus 
cutting off all communication between the posterior nasal 
chamber and the mouth, and at the same time the Eusta- 
chian tubes are rendered more patulous by the action of the 
levator palati and other muscles, so that air forced into the 
nose by Politzer's method, having no other way of exit, 
readily finds its way into the middle ear through the tubes. 
The same thing may be accomplished with greater con- 
venience by requesting the patient to " puff out his cheeks " 



PATENCY OF EUSTACHIAN TUBES 



321 



and compressing the air-bag while the mouth is thus inflated 
with air. Pronouncing certain syllables, like the words Jiicky 
hack, /lock, also causes an elevation of the soft palate and a 
dilatation of the Eustachian tubes, so that the middle ear 
can readily be inflated by means of Politzer's air-bag. The 
middle ear of young children is usually more easily inflated 
by means of Politzer's air-bag than those of adults, while 
in the case of infants air 
readily enters the middle ear 
if Politzer's air-bag be used 
while the child is crying. 

No more force should ever 
be employed in compressing 
the rubber bag than is abso- 
lutely necessary to force air 
into the middle ear, and it is 
far better for the aurist to 
make several unsuccessful 
efforts to accomplish this 
purpose than to drive air 
into the middle ear with suf- 
ficient force to cause pain. 
While it is probably impos- 
sible to rupture a normal 
membrana tympani with Po- 
litzer's air-bag, yet several 

cases have been reported in which an atrophied or diseased 
drum-membrane has been ruptured by the incautious use 
of this instrument. 

The Eiisiachian catheter is a tube of rubber or metal 
curved at its distal extremity, as shown in Fig. 188. The 
proximal end of the instrument is so constructed that the 
nozzle of Politzer's air-bag will fit loosely into it, and it is 
provided with a ring or mark of some sort by wdiich the 
aurist is informed of the position of the beak of the instru- 
ment when it has been inserted in the nose. At least 
three sizes of this catheter should be in possession of the 
aurist — respectively i, 2, and 3 millimeters in diameter. 
The hard-rubber catheters have the advantage of cheapness, 
but they are not so easily disinfected as are the metal ones, 
21 




Politzer's air-bag. 



322 DISEASES OF THE NOSE, THROAT, AND EAR 

which can be dropped into water and boiled or sterilized by 
pouring some alcohol over them and setting it on fire. 
Moreover, the hard-rubber instruments have a diameter 
larger in proportion to the size of their caHbre than that of 
the silver catheters. The best catheters are made of pure 
or, as it sometimes is called, " virgin " (in contradistinction 
to " coin ") silver, which insures a certain degree of flexibility. 
The cheap brass, nickel, or silver-plated instruments are 
clumsy, and are so hard, brittle, and inflexible that the 
curve of the beak cannot be slightly changed readily, as in 
the case of the softer pure silver instruments. The distal 
extremity should be slightly knobbed, smooth, and round. 
What is known as Hartmann's catheter is probably the best 
model (Fig. i88). It should be only sufficiently long to 
project about I inch from the anterior naris when the beak 
of the instrument is placed in the Eustachian tube-mouth. 



Fig. i88.— Hartmann's silver Eustachian catheter. 

In 1724, M. Guyot, a postmaster at Versailles, proposed 
to treat ear diseases by injections into the Eustachian tube 
by means of a catheter introduced through the mouth, "for 
the removal of obstructions in that canal and also the 
middle ear." 

In 1 741, Archibald Cleland, an English army surgeon, 
pubHshed an account of " instruments proposed to remedy 
some kinds of deafness proceeding from obstructions of the 
external and internal auditory passages." Cleland recom- 
mended " lubricating " the Eustachian tube by throwing a 
little warm water into its pharyngeal orifice through a 
flexible silver tube introduced through the nose into the 
Eustachian tube. The proximal end of Cleland's catheter 
had affixed to it a sheep's ureter, '' whereby warm water 
may be injected, or they will admit to blow into the Eusta- 
chian tube and so force the air into the barrel of the ear and 
dilate the tube sufficiently for the discharge of the excre- 
mentitious matter that may be lodged there." 



K US TA cm AN CA THE TER 323 

Clcland also used probes or bougies to exi)lore the 
Eustachian tube through the nose. The use of bougies 
through the l^^ustachian catheter soon became quite popular 
and was shamefully abused, according to Wilde, who prac- 
tically abandoned their use by contenting himself witli in- 
troducing into the Eustachian tube for a short distance only 
a decalcified bone bougie, the end of which was made 
flexible by boiling water. His contemporary, Kramer, a 
distinguished Berlin aurist, used catgut bougies, which he 
stated he pushed along the tube in certain cases until the tip 
was visible between the handle of the malleus and incus. 

Introduction of the Beak of the Catheter into the Eustachian 
Tube. — The operator should first inspect the anterior narium 
and note the position, size, and shape of any obstruction, 
such as a septal exostosis, which will interfere with the 
passage of the catheter. The operator should hold the 
proximal extremity of the catheter between the thumb and 
fingers of his right hand, somewhat in the manner of a pen- 
holder, and lift up the tip of the patient's nose with the 
thumb of his left hand. The beak or distal extremity of 
the catheter is then inserted within the nares and is made to 
rest upon the floor of the nose, while the proximal end of 
the instrument is elevated until it is parallel with the floor 
of the nose. Still keeping the beak of the instrument in 
contact with the floor of the nose, the catheter is pushed 
gently inward until the beak of the instrument is felt to be 
in contact with the posterior wall of the pharynx. At this 
stage the operator has the choice of the three methods of 
procedure in common use. 

Probably the one most frequently employed is that of 
Lowenburg, who directs that when the beak of the instru- 
ment is felt to be in contact with the pharyngeal wall the 
catheter should be rotated medianly through an angle of 45 
degrees, and drawn forward until the beak of the instrument 
is felt to touch the posterior edge of the septum, when it is 
rotated outward through rather more than an angle of 90 
degrees, and should then be in the mouth of the Eustachian 
tube. The operator may feel satisfied that this is the case 
if the beak of the catheter is found to be somewhat firmly 
fixed in the position it has assumed, so that it is impossible 



324 DISEASES OF THE NOSE, THROAT, AND EAR 

to rotate the beak of the instrument upward or carry it 
backward or forward without exerting considerable force. 

Gruber directs that when the beak of the catheter is felt 
to be in contact with the pharyngeal wall it should be 
withdrawn until its curved portion comes into contact with 
the posterior margin of the hard palate. It should then be 
again pushed inward a distance of about \ inch, and rotated 
outward toward the ear through an angle of a little more 
than 45 degrees, when, if these maneuvers have been suc- 
cessful, the beak of the instrument will be within the mouth 
of the Eustachian tube. 

When the beak of the instrument is felt to be in contact 
with the pharyngeal wall it may be immediately rotated out- 
ward 45 degrees, which will carry the beak of the instru- 
ment into Rosenmiiller's fossa. The catheter should now be 
drawn gently outward until its beak is felt to slip over the 
posterior lip and into the mouth of the tube. An operator 
soon learns by the sensation imparted to his hand whether 
the beak of the instrument is or is not in the Eustachian 
tube. 

Obstacles to CatJictcrizatioii of the Eustachian Tubes. — 
Deviation of the septum may render the passage of a 
Eustachian catheter through that side of the nose impos- 
sible. Under such circumstances both Eustachian tubes may 
be catheterized through the unoccluded nostril. To reach 
the tube of the opposite side it will be necessary to have 
the beak of the catheter somewhat longer than that of the 
instrument shown in Fig. 188. 

Ecchondroses or exostoses of the septum frequently in- 
terfere with the easy passage of the catheter through the 
inferior meatus of the nose. Under such circumstances the 
beak of the catheter can sometimes be passed over them 
and made to rest upon the floor of the nose or the soft 
palate behind. In some such instances a soft-rubber cathe- 
ter can be used to advantage. In passing the catheter 
through the nose the instrument should be held very lightly 
between the thumb and finger, and a tendency to rotate on 
its long axis should not be resisted, because by allowing the 
instrument to rotate its beak will sometimes glide around 
an obstruction and finally find its way into the pharynx. 



OBS TA CL ES TO CA THE TERI'/A 7 'ION 



325 



Another obstacle to catheterization of the Eustachian 
tubes results from spasmodic contraction of the muscles of 
the palate and pharynx, which tightly grasp the beak of 
the instrument and interfere with its proper manipulation. 
Gentleness and patience on the part of the surgeon will 
generally overcome this difficulty. The patient should be 
requested to inhale deeply through his nose, to ** swallow," 
or say " One," and thus produce a temporary relaxation of 
the parts, which, if repeated from time to time, will gener- 
ally enable the surgeon to guide the beak of the catheter 
into the mouth of the Eustachian tube. 




Fig. 189. — Auscultation of the ear. 



When the beak of the catheter is felt to be within the 
mouth of the Eustachian tube it should be held in position 
with the thumb and forefinger of the left hand and steadied 
by two fingers resting upon the patient's face (Fig. 189). 
The nozzle of the air-bag is then fitted loosely into the prox- 
imal end of the catheter and compressed with the right 
hand. If the aitsadtation-tiibe be employed at the same 
time, air will be heard to enter the patient's middle ear with 
a sound somewhat similar to that produced by inflating the 



326 DISEASES OF THE NOSE, THROAT, AND EAR 

middle ear by Valsalva's or Politzer's method. However, 
when the catheter is employed the sound seems as if pro- 
duced nearer the surgeon's ear. 

The inflation of the middle ear by means of the Eustachian 
catheter is not altogether devoid of risk. Deaths have been 
reported. The fatal results in these instances may have 
resulted from injection of air through a rent in the mucous 
membrane made by the beak of the catheter, which subse- 
quently found its way beneath the mucous membrane to a 
position where the emphysema caused sufficient obstruction 
to respiration to occasion suffocation. 

The writer saw 2 cases where young and inexperienced 
operators had injected a sufficient amount of the air con- 
tained in a Politzer bag through a Eustachian catheter into 
the cellular tissue to cause decided swelling of the tissues of 
the neck. In these 2 cases the patients simply suffered a 
certain amount of discomfort for a few hours, the air in the 
tissues being finally absorbed. 

Solutions may be sprayed through the catheter by means 
of an ordinary atomizer by inserting the nozzle of the atom- 
izer into the catheter. Either the compressed-air apparatus 
or the hand-bulb maybe used to produce the spray. Under 
ordinary circumstances the spray probably does not pene- 
trate the tube further than the isthmus, except the patient 
be told to swallow, when the spray may be heard through 
the auscultation-tube to enter the tympanum, sounding not 
unhke drops of rain falling on a tin roof When compressed 
air is used to produce the spray it should be employed 
gently and with due caution. The automatic cut-off should 
be manipulated in such a manner as to throw the spray gently 
and by successive puffs into the Eustachian-tube orifices. 
The drip of the solution that condenses in the catheter 
should, at the completion of the treatment, be blown into 
the Eustachian tube by means of Politzer's bag. 

Instead of employing an atomizer, fluid may be inserted 
within the catheter by an ordinary glass medicine-dropper 
and thrown into the tube with Politzer's bag, or fluid may 
be syringed through the catheter into the Eustachian tube, 
and when the drum-head is perforated, through the Eusta- 
chian tube and tympanum into the external auditory canal. 



CArilETEKrAATION OF rilE MWDLE EAR 



327 





For this purpose syringe a, Fig. 38, with nozzle 7, fitted into 
an ordinary Eustachian catheter, answers the purpose, or 
the apparatus of Clevenger (Fig. 190) may l^e employed. 

When the drum-head is intact fluid 
enters a narrow Eustachian tube be- 
yond the isthmus only with great dif- 
ficulty, having to compress before it 
the air contained in the middle ear. 
As soon as the pressure is relaxed 
the spring or rebound of the com- 
pressed air generally throws into the 
pharynx fluid contained in the tube. 
However, during the act of swallow- 
ing fluid may be made to penetrate 
into the cavity of the tympanum 
through the Eustachian tube even 
when the drum-head is intact, the 
muscular action in opening and shut- 
ting the tube during swallowing doubt- 
less playing an important role under 
such circumstances. In this manner 
sea-water or fresh water introduced 
into the pharynx while bathing some- 
times reaches the tympanum and al- 
most invariably produces an acute 
otitis media. The writer has observed 
the sam.e thing occur during the use 
jof the Birmingham douche or even 
from sniffing normal salt solution into 
the nose from the hollow of the hand. 

The introduction of watery solu- 
tions, even of the blandest character, 
is therefore not devoid of risk unless 
the drum-head is lacking or contains 
a large perforation. Bland oily fluids, 
on the other hand, can be sprayed 

or syringed into the middle ear with impunity. When 
a watery fluid is used to wash out the Eustachian tube 
the operator should be careful to inflate the middle ear 
several times by means of Politzer's method in order 




Fig. 190. — Clevenger's in- 
strument for direct medication 
of Eustachian tube. 



328 DISEASES OF THE NOSE, THROAT, AND EAR 

to remove any excess of fluid that might otherwise re- 
main. 

Solutions of protargol, lo to 50 per cent., nitrate of silver, 
J to I per cent., potassium iodid, i per cent, (in syphilis), 
raay safely be introduced into the mouth of the Eustachian 
tube. 

An Allen's probe (Fig. 35), sufficiently long to extend \ 
inch beyond the catheter mouth, may be used as an appli- 
cator by wrapping a few fibers of cotton about its tip and 
dipping the end of the probe into the solution to be used. 
After the beak of the catheter is in position the cotton- 
tipped probe is passed through it and an application of the 
remedy made to the first \ inch of the Eustachian tube, or 
the end of a cotton-tipped Allen's probe, after being dipped 
into any appropriate solution, may be passed like a catheter 
through the nose into the nasopharynx and the cotton- 
tipped end inserted into the mouth of the Eustachian tube. 

Eustachian bougies are occasionally used for the dilation of 
strictures of the Eustachian tube and other purposes. They 
are filiform in character and a number of sizes are obtainable, 
made of whalebone, hard rubber, celluloid, or gold, for 
electrolysis of stricture. They are inserted into the Eus- 
tachian tube through a catheter. Great gentleness should 
be used in passing a Eustachian bougie for the first time 
through an inflamed tube, for it is easy to penetrate tissue 
with so small an instrument and make a false passage. The 
length of the catheter employed should be marked upon the 
bougie and also the length of the Eustachian tube, which is 
about I J inches ; and this last mark cannot be passed with- 
out danger of injury to the tympanic contents or penetrat- 
ing the drum-head. 

Not much force is necessary to pass a Eustachian bougie 
through a normal tube. When a stricture is encountered 
gentle pressure will usually finally overcome the obstruction, 
after which the bougie passes readily onward. The most 
frequent position of stricture is at the isthmus. 

Before attempting to pass the bougie a few drops of 
albolene should be inserted in the catheter and blown 
into the Eustachian tube by means of Politzer's bag. If a 
stricture is passed the bougie should be allowed to remain 



DISEASES OE THE EXTERNAL EAR 329 

in position for five or ten minutes. After the bougie is with- 
drawn the middle ear should be gently and cautiously in- 
flated. If there be reason to suppose that during the pas- 
sage of the bougie the mucous membrane has been torn, it 
will be safer to dispense with inflation, lest air penetrate the 
cellular tissue. 

Electrolysis of Eustachian strictures has been done by 
Duel by means of an insulated Eustachian catheter and gold 
bougies, of which he has designcfl three sizes. The amount 
of current necessary to overcome an obstruction and promote 
absorption of a stricture is 3 to 5 milliamperes, which should 
be turned on as soon as an obstruction is felt and continued 
for not longer than three to five minutes. The negative 
pole of the battery is attached to the bougie, the positive 
held in the patient's hand or applied to the nape of his neck. 
There is little pain produced by the procedure, which may 
be repeated at intervals of a week. Inflation should not be 
practised immediately after the use of the electric bougie, 
but the patient may return the next day to have his middle 
ear inflated. 

DISEASES OF THE EXTERNAL EAR 

Congenital Defects. — The auricle may be wanting entirely 
or there may be a plurality of auricles (Fig. 191). The 
auricle may be abnormal as regards position or shape or it 
may only be partially developed. Malformations of the auri- 
cle are generally associated with defects or absence of the 
external auditory canal (Fig. 192) and sometimes imperfect 
development of the deeper portions of the auditory appara- 
tus. A congenital fistula is sometimes seen about the ex- 
ternal ear and may communicate with the tympanic cavity 
(Fig. 193). Excessive development or lack of development 
of the external ear is due to excessive or imperfect develop- 
ment in the closure of the first branchial cleft during embry- 
onic life. Various operations have been devised to correct 
deformities of the auricle and open a way down to the tym- 
panum in cases of stenosis of the external auditory canal. 
Plastic operations in this locality do well as regards the 
healing process. Operations for the correction of atresia or 



330 DISEASES OF THE NOSE, THROAT, AND EAR 

stenosis of the external auditory canal hitherto have not 
been successful. 

Othematoma or perichondritis of the auricle (Fig. 194) is 
generally the result of direct violence — self-inflicted in the 




Fig. 191. — Supernumerary auricle in the neck {Lancet, 1888). 

insane, among whom the disease is not uncommon. This 
affection is characterized by an effusion beneath the peri- 
chondrium of the auricle, causing swelhng, tension, and pain 





Fig. 192. — Congenital deformity of 
the auricle (Sexton). 



Fig. 193. — Convoluted auricle with 
congenital fistula (Sexton). 



in the part. , The effusion may finally escape through an 
external opening which it has made for itself, remain as a 
swelling for an indefinite time, or slowly be absorbed. Even 



DISEASES OF THE EXTERNAL EAR 



331 



when rcabsorption of the effusion does occur, considerable 
deformity of the auricle may result (Fig. 195). 

Trcatnioit. — In the insane, hematoma of the auricle 
is best let alone, unless the local inflammation is suffi- 
ciently great to indicate that infection has occurred and 
that the effusion has become purulent. If necessary 
inflammation should be combated by the application of 
ichthyol ointment, 20 per cent, in lanolin (adeps lanae 
hydros us), and progressive effusion by painting the affected 





Fig. 194. — Medium-sized othematoma of 
the auricle (Sexton). 



Fig. 195.— Deformity of the auricle 
due to othematoma (Sexton). 



parts with contractile collodion and the use of a press- 
ure bandage. Absorbent cotton is placed between the 
auricle and the head and a pad of cotton over the auri- 
cle, and pressure maintained by means of a roller bandage 
over the auricle and around the head. The bandage should 
not be applied with sufficient firmness to cause pain or great 
discomfort. If, notwithstanding these measures, the collec- 
tion of fluid beneath the perichondrium increases, the parts 
should be aspirated with antiseptic precautions — a measure 
that will probably need repetition from time to time. In 
cases where the inflammation is great and the effusion be- 
neath the periosteum is evidently purulent, it is best to lay 



332 DISEASES OF THE NOSE, THE OAT, AND EAR 

the parts freely open, wash out the pus-cavity with subU- 
mate solution, and pack with iodoform gauze. The incision 
should be sufficiently free to permit of easy dressing and the 
ready removal of sloughing cartilage as soon as separated 
from the living tissue. Fortunately the number of cases 
where the injury to the auricle is sufficently severe to cause 
sloughing of even a small portion of the cartilage are com- 
paratively few. 

Chronic perichondritis is a chronic inflammation of the 
cartilage of the auricle observed in boxers and others 
whose ears are constantly subjected to irritation or slight 
traumatism. 

Treatment consists in gentle massage and applications of 
ichthyol ointment (20 per cent.) at bedtime, with the avoid- 
ance of the cause of the irritation. 

Incised and punctured wounds after thorough cleansing 
should be sutured in such a manner as to leave as httle 
scar as possible upon the lateral surface of the auricle. In 
contused and lacerated wounds perichondritis almost invari- 
ably occurs, and it is well to anticipate such an attack by 
the application of a wet bichlorid dressing for twelve to 
twenty-four hours. An attempt should be made to save as 
much tissue as possible and no part which possibly may 
have sufficient vitality to live should be removed. As a 
primary measure but few sutures should be used, as after 
the circulation has been thoroughly established it is 
ordinarily a simple matter to secure more perfect coaptation 
of the parts and prevent deformity. The sutures should 
not be passed through the cartilage unless absolutely neces- 
sary, although no great harm usually results from a suture 
through the cartilage of the auricle. 

Fracture of the base of the skull involving the temporal 
bone may extend into the auditory canal in some cases 
without rupture of the membrana tympani. Hemorrhage 
from the ear may be somewhat profuse or scanty. In 
addition to the general treatment the ear should be thor- 
oughly cleansed of clots by gentle syringing with a warm 
bichlorid solution (i : 1000), dried, and covered with pow- 
dered boric acid, except where oozing persists, when the 
auditory canal should be very lightly packed with sterile 



DISEASES OE THE EXTERNAL EAR 333 

iodoform gauze. The ear should be gently cleansed once 
a day with the bichlorid solution and packed with gauze as 
long as oozing persists ; after which the parts are best kept 
as dry as possible by cleansing when necessary with bi- 
chlorid solution, thoroughly drying the parts, and insufflat- 
ing powdered boric acid. A light plug of iodoform gauze 
may be loosely inserted into the concha for a few days. 
Boric acid in sufficient quantity to cover the w^ound is 
apparently sufficient to prevent infection. Packing the 
canal maintains a warm and moist condition of the w^ound 
that should be avoided. 

Cleft lobule, which is generally the result of the tear- 
ing out of an earring, is common and may be uemedied 
by the following operation : The sides of the cleft are 
freshened in the same manner as for a hare-lip operation ; 
but, to avoid as far as possible the formation of a con- 
spicuous scar, the sutures should be introduced and tied 
on the inner side of the lobule, and should involve only the 
deeper layers of the skin of its outer surface. After the 
parts have been accurately adjusted and the sutures tied, 
the wound should receive further support by the application 
of iodoform collodion. If the operation be done under 
antiseptic precautions it is generally successful. 

Keloid of the auricle, orio-inatino; in the scar resulting 
from piercing the ear for earrings, is not uncommon, espe- 
cially in the negro. The growth consists of a hard nodule 
of fibrous tissue, generally tender on pressure. If large it 
should be removed by the knife. There is a tendency for 
the grow^th to recur. Encouraging results have been 
reported from the application of the .f-ray in cases where 
the growth has recurred after removal by the knife. 

CUTANEOUS DISEASES OF THE AURICLE 

The cutaneous diseases w^hich sometimes attack the 
auricle are hyperemia, frost-bite, burns, eczema, dermatitis, 
comedo, erysipelas, syphiloderma, herpes, lupus, and im- 
petigo contagiosa. 

Hyperemia may be either active or passive, transient or 
chronic in character. There is an increase in the blood 



334 I^ISEASES OF THE NOSE, THROAT, AND EAR 

supply of the auricle and generally of the canal, so that 
the skin appears redder than normal and feels hot to the 
patient. Mild cases are due to some transient vasomotor 
disturbance that usually soon passes away without treat- 
ment. In some individuals a single comparatively small 
dose of quinin, salicyHc acid, or chlorid of calcium will 
produce hyperemia of the auricle and canal that may per- 
sist for some time. 

Active hyperemia of the auricle may result from exposure 
to cold, sunburn, or other irritants. Passive hyperemia of 
the auricle and canal are sometimes present as the result of 
gout, valvular disease of the heart, or any organic disease 
capable of producing localized blood stasis. 

Treatment. — The best local application is probably liquor 
plumbi subacetatis, which may be painted on the parts 
once or twice a day. Nervous cases will need building up ; 
the gouty, a correction of the constitutional dyscrasia. 

Dermatitis is an inflammation of the skin generally result- 
ing from some injury, such as the bite of an insect, a blow, 
fall, stab, wound, etc. 

The symptoms vary from slight inflammation of the skin 
at the point of injury to localized gangrene. 

Treatment. — This varies with the severity of the inflam- 
mation and the character of the infection. Mild cases 
do well by simply painting with liquor plumbi acetatis. 
The severer cases require a wet dressing of bichlorid of 
mercury, as in infected wounds of other parts oi the body. 
The dermatitis following the sting of insects is treated by 
a wet dressing of 20 per cent, bicarbonate of sodium. 

Frost-bite. — In cold climates frost-bite of the auricle is by 
no means uncommon. At first the auricle is cold and 
numb and sometimes stiff, as if actually frozen solid. Later 
on the symptoms are those of traumatism, involving only 
the skin or the skin and deeper structures. The skin is 
hot and swollen, frequently excoriated or covered by 
vesicles. In the severer cases the symptoms are those of 
perichondritis, followed sometimes by cartilaginous necrosis 
and the formation of sinuses upon either surface of the 
auricle. 

Treatment. — When the auricle is frozen its temperature 



DISEASES OE THE EXTERNAL EAR 335 

should be restored gradually by gentle friction with snow 
or pounded ice, and afterward by gentle manipulation with 
the fingers. If only the skin is involved by the subsequent 
inflammation satisfactory results will follow the application 
of a 10 percent, ichthyol ointment in vaselin, which should 
be applied sufficiently often to keep the parts constantly 
covered and protected by the ointment. In some cases pain 
and soreness are greatly relieved by wrapping the auricle 
in absorbent cotton after using the ointment and applying 
gentle pressure by means of a bandage. When perichon- 
dritis follows frost-bite of the auricle it should be treated in 
the manner already described. When sinuses have formed, 
they should be laid open, the necrosed tissues removed, 
and the wounds allowed to heal by granulation. If care 
is taken to keep the parts properly supported but little 
deformity sometimes results. 

Burns. — The auricle is liable to burns, sometimes severe, 
and involving not only the surrounding neck and scalp 
but also the auditory canal. A common cause of slight 
burn of the auricle sufficient to raise a blister is hot appli- 
cations for the relief of the pain of otitis media. 

TrcaUncnt. — Pain is best relieved by the local use of cold, 
applied either in the form of an ice-bag or napkins wrung 
out of ice-water. The application of cold should be con- 
tinued as long as it affords relief 

Charred and dead tissue, if the burn is a severe one, 
should be at once removed, and the parts cleansed from 
soot and dirt by means of copious washings with a solution 
of bicarbonate of sodium. The parts are then dusted with 
orthoform or smeared wath a 3 per cent, carbolized petro- 
leum, a bandage applied, and over this an ice-bag is placed 
as long as the cold seems necessary for the relief of pain. 
Excessive pain not quickly relieved by these measures will 
require a hypodermic of morphin. 

When the skin is unbroken the best dressing is the so- 
called carron oil (equal parts of linseed oil and lime-water). 
This is smeared thickly on patent lint and applied to parts 
after they have been cleansed with bicarbonate of sodium 
solution. 

Herpes. — Herpes of the auricle is similar to the disease 



336 DISEASES OF THE NOSE, THROAT, AND EAR 

when it occurs upon the skin in other locahties. It is 
characterized by vesicles filled with a clear serum, appearing 
singly or in groups, upon the helix or about the lobule. 
The surrounding skin is reddened, slightly swollen, and 
tender to the touch. There may be slight fever, pain, and 
itching of the auricle. The affection is due to some nervous 
disturbance. The vesicles ordinarily dry up and disappear 
by the end of ten days or two weeks. 

Treatment, — The milder cases are best treated by gentle 
purgation with citrate of magnesia or one of the other 
saHnes. The vesicles should be painted three or four times 
a day with camphorated tincture of opium (paregoric). 
This application seems to allay the slight itching and burn^ 
ing better than most others and hastens absorption. 
Should the contents of the vesicles become purulent the 
vesicles should be opened and the parts washed with 
bichlorid solution and dusted with powdered calomel. 

Impetigo contagiosa is an acute contagious disease of the 
skin sometimes encountered upon the skin of the auricle or 
nose in dispensary practice. It begins as small discrete or 
confluent vesicles, which rupture and leave a granular surface 
resembling closely a vaccination sore. It is contagious, 
but no characteristic organism has as yet been isolated. 
Recovery usually occurs within a week under antiseptic 
treatment. 

Treatment consists in keeping the parts clean by washing 
with bichlorid solution and applying either powdered cal- 
omel or an ointment of ammoniated mercury. 

Lupus vulgaris is a chronic tuberculosis of the skin of the 
auricle, either primary or extending to the auricle from the 
skin of the face. The disease begins as a tubercle deep in 
the skin. The dull reddish tubercles are sometimes years 
in developing, but finally break down into a characteristic 
ulceration which may heal at one extremity while it is 
spreading in another direction. The disease is exceedingly 
chronic and years may go before a large portion of the 
auricle is involved. After healing has occurred the auricle 
is shriveled, shrunken, and deformed. 

Diagnosis. — The diagnosis is usually made by the appear- 
ance of the ulcer and the history of extreme chronicity. 



DISEASES OF THE EXTERNAL EAR 337 

The disease might be mistaken for cither sypliihs or epithe- 
Homa, but each is much more ra[)id in its course. 

Treatment. — The internal medication consists in the admin- 
istration of cod-Hver oil and arsenic. The local treatment 
consists in a thorough cureting of the ulceration and the 
application of the solid stick of nitreite of silver. This 
should be followed by cautious applications of the ;i'-ray for 
ten minutes every other day. 

Syphilis. — Primary sypliilis of the auricle is naturally rare, 
but the auricle may become inoculated by a bite or other 
cause. Chancre of the auricle differs in nowise from the 
primary lesion elsewhere upon the skin. It is an ulcer 
with indurated edges and a hard base generally conforming 
to the papular type. The lymphatics of the neclc are 
swollen. 

Secondary sypliilis of the auricle is generally part of a 
syphiloderm involving more or less of the whole body. 

Tertiary syphilis of the auricle consists of a gumma either 
before or during the stage of ulceration. 

Diagm^sis of the primary lesion is sometimes difficult 
unless there is the history of a bite or injury by a syphilitic 
individual. The diagnosis in the secondary stage is usually 
easy. In the tertiary stage, however, an ulcerating gumma 
may be mistaken for either lupus or epithelioma, and it will 
usually be necessary to administer iodid of potassium in 
increasincT doses before comino" to a definite conclusion. 

Treatiueiit. — The constitutional treatment differs in nowise 
from that of syphilis of the nose, pharynx, or laiynx 
already described. 

Congoiital syphilis is usually of the tertiary variety. Its 
treatment differs in no respect from the acquired disease. 
The writer remembers only i case observ^ed by him, that of 
an infant about eight months old, with an ulcerating gumma 
of the meatus. The external orifice of the meatus was 
nearly occluded by exuberant granulations, which were 
snared away and the parts kept clean and dusted with cal- 
omel powder. The internal treatment consisted of gray 
powder and inunctions of mercury. The infant made a 
good recovery. 

Erysipelas is the result of infection of the skin with the 
22 



338 DISEASES QE THE NOSE, THROAT, AND EAR 

streptococcus erysipelatosa of Fehleisen. It is presumed 
to only invade the skin through some traumatism, possibly 
so minute as to be overlooked. The writer saw in consul- 
tation 2 cases that had their origin in a blister produced by 
painting the mastoid process with cantharidal collodion. In 
both these cases, occurring in old men, the erysipelas ex- 
tended to the scalp ; in one with a fatal result. Er}'sipelas 
of the auricle may extend along the canal and involve the 
drum-head. 

Symptoms are those of erysipelas in other localities. 
The disease is usually ushered in by a chill and high 
temperature. There is headache and anorexia. The 
infected area is red and swollen and the swelling and red- 
ness somewhat rapidly spreads until sometimes the entire 
auricle is involved and the disease has attacked adjacent 
skin areas. Vesicles filled with serum may or may not 
appear. 

Treatment. — The patient, if in a hospital, should be isolated 
from other surgical cases. It is well to begin treatment with 
a calomel purge (-1-gr. every hour until i^gr. hav^e been taken), 
followed by a bottle of the solution of citrate of magnesia. 
As soon as the bowels have acted freely the patient should 
take 20 drops of the tincture of the chlorid of iron every two 
or three hours and 3^ gr. of strychnin every four hours. 
It is said that some cases can be aborted by painting the 
infected and adjacent skin area with carbolic acid, which is 
allowed to remain until it has blanched the skin surface. 
The excess of acid is then washed off with alcohol. Most 
of the writer's cases have been treated locally by applica- 
tions of 20 per cent, ichthyol in lanolin, which was smeared 
thickly on patent lint and applied to the parts. The treat- 
ment is effective, but somewhat dirty. Those cases of facial 
erysipelas seen in the Philadelphia Hospital during his terms 
of service there were treated locally by applications of patent 
Hnt kept moist with a 10 per cent, solution of protargol. 
Apparently one treatment was about as effective in con- 
trolling the local symptoms as the other. 

Phlegmonous erysipelas is a severe form of erysipelas 
involving the deeper structures beneath the skin with the 
formation of abscesses. It is generally the result of mixed 



DISEASES OE THE EXTERNAL EAR 339 

infection, the streptococcus eiysipelatosa and the strepto- 
coccus or staphylococcus pyogenes being found in the dis- 
charges. 

The symptoms are those of severe crysipehis — high fever, 
redness, pain, and great swelHng of the auricle, with forma- 
tion of pus and exfoliation of cartilage. 

Trcatmoit. — The auricle should be covered with a dressing 
kept constantly wet with bichlorid solution (i : 1000). As 
soon as the presence of pus is suspected the parts should 
be freely incised down to the cartilage. The wound should 
be syringed daily with a bichlorid solution and, if necessary, 
packed with gauze in such a manner as to secure perfect 
drainage. 

Gangrene is, in modern times, an extremely rare disease, 
but is said to occur occasionally either in the moist or dry 
form. 

Treatment. — This is similar to that of phlegmonous er- 
ysipelas. Iron and strychnin should be given internally. 
The parts should be kept covered with a wet bichlorid 
dressing and every effort made to secure asepsis. Necrotic 
tissue should be removed as soon as possible. Localized 
pain can be controlled by dusting with iodoform and, when 
this is ineffective, with orthoform. 

The disease is very contagious, at least to other surgical 
cases. Therefore the patient should be carefully quaran- 
tined and all dressings, towels, etc., used about the case 
destroyed. 

Eczema is by far the commonest of the skin diseases affect- 
ing the auricle. It may also involve the auditory canal 
and even the dermoid layer of the membrana tympani. 
Intertrigo resulting from the invasion by the disease of the 
fissure formed by the junction of the auricle with the 
mastoid region is of frequent occurrence in infants and 
young children. 

Treatment. — In adults the disease is sometimes the result 
of the rheumatic or gouty diathesis, and, in addition to 
local treatment, such cases require the administration of 
alkaHes, with iodid of potassium, salicylate of sodium, or 
arsenic. In children the disease is frequently associated 
with struma, and for such cases cod-liver oil or syrup of 



340 DISEASES OF THE NOSE, THROAT, AND EAR 

the iodid of iron should be prescribed. Eczema intertrigo 
is best treated by the frequent application of powders, and 
oxid of zinc or subnitrate of bismuth may be prescribed 
for this purpose. 

The commonest cause of eczema of the auricle in children 
is an irritating discharge from the middle ear. In the ne- 
glected infants of the poor the discharges resulting from 
purulent inflammation of the tympanum are frequently 
smeared by the fingers of the child over the entire auricle 
and over the skin in front of and behind the ear. Under 





Fig. 196. — Dermoid of the auricle and 
nevus of the palpebral conjunctiva (after 
Lannelongue). 



Fig. 197. — Cartilaginous tumor in front 
of the left ear of a newborn infant (Friih- 
wald). 



such circumstances the auricle and surrounding skin be- 
come covered by eczematous scabs and crusts. These the 
surgeon should carefully remove by means of pledgets 
of cotton saturated with peroxid of hydrogen, and rub well 
into the affected parts an ointment consisting of 6 or 8 gr. 
of the yellow oxid of mercury to I ounce of petrolatum. A 
single thorough application of this remedy is sometimes 
sufficient to bring about great improvement, even in cases 
in which the disease has existed for several months. Per- 
fect cleanliness in all cases should be enjoined, and if fre- 



DISEASES OF THE EXTERNAL EAR 34 1 

qucnt cleansinf^ of the auditory canal with absorbent cotton, 
followed by insufflations of powdered boric acid, is not 
sufficient to keep the concha dry and free from the discharge, 
the skin of this part of the ear should be protected by some 
bland ointment. Ik^nzoated zinc ointment, if frcsJi and 
properly made, answers very well for this purpose. 

The new growths that occur on the auricle are sebaceous 
cyst, fibroid tumor, epithelioma, nevus, sarcoma, and cornu 
cutaneum. 

The treatment is the same as if the new growths occurred 
elsewhere. Nevi in suitable cases should be treated by 
electrolysis. The other growths ordinarily require excision. 

DISEASES OF THE EXTERNAL AUDITORY CANAL 

The more common affections of the external auditory 
canal are acute circumscribed inflammation or furunculosis, 
acute and chronic diffuse inflammation, diphtheritic inflam- 
mation, hyperostosis, exostosis, and foreign bodies. 

Furuncle or Acute Circumscribed Inflammation. — Recurrent 
attacks of furunculosis of the auditory canal seem, in many 
instances, to be the result of irritation from carious teeth or 
from disease of the interior of the nose and throat. The 
affection is commonest in gouty or anemic and debilitated 
individuals and in women suffering from menstrual disorders. 

Pathology.- — In most instances the starting-point of the 
disease is a sebaceous gland or a ceruminous follicle, which 
has become inoculated with the staphylococcus pyogenes 
aureus or other pus-forming bacteria by scratching the ear 
with a dirty finger-nail, hairpin, match-stick, etc. Metastatic 
abscess in the canal is said to sometimes occur in gonor- 
rhea. The inflammation usually soon becomes a circum- 
scribed perichondritis or periostitis of the auditory canal. 
The pathology of acute circumscribed inflammation of the 
external auditory canal is similar to that of boils and felons 
occurring elsewhere on the body. 

Symptoms. ^ThQVQ is at first an itching within the canal, 
a portion of which is found tender to the touch, and soon 
becomes painful. Little by little the pain and tenderness 
increase, until in some instances the patient's sufferings 



342 DISEASES OF THE NOSE, THROAT, AND EAR 

become almost unendurable. In severe cases the pain, 
which at first was confined to the ear, extends to the whole 
side of the head, is throbbing in character, and is increased 
by movements of the jaw in talking, eating, etc. There is 
some elevation of temperature in the severest cases. Deaf- 
ness is not a marked symptom until the swelling is large 
enough to close the canal at the part involved, but tinnitus 
is present in the majority of cases. The furuncle will rup- 
ture spontaneously in from two to eight days, according as 
the inflammation is superficial or deep seated. The dis- 
charge is purulent, sometimes quite profuse ; and its appear- 
ance is speedily followed by a subsidence of acute pain ; 
the parts, however, remain sore for several days. A " core." 
or small slough of the skin, as in boils elsewhere, usually 
exfoliates before the parts heal. 

Treatment. — Speedy relief generally follows a free incision 
through the swollen parts down to the cartilage or bone, 
even though no pus be found. The incision should be 
followed by syringing the canal with hot boric acid solution, 
the insertion into the canal of a cone of absorbent cotton 
covered with a lo per cent, ointment of cocain in lanolin, 
and the application of heat. 

In cases where incision is not advisable a cone of cotton 
should be well covered with an ointment of the yellow oxid 
of mercury (6 gr. to i ounce of vaselin), and so placed 
within the canal that it will exert pressure upon the swollen 
parts. For a few moments this procedure increases the 
pain somewhat, but it is followed by a feeling of decided 
relief and comfort. The ointment is rubbed into the skin 
of the canal by each movement of the jaw in talking and 
eating, and if the treatment is applied early enough many 
cases of furunculosis of the auditory canal may be aborted 
before suppuration has occurred. Cotton cones are readily 
made by selecting a piece of absorbent cotton about 2 
inches long and about f inch wide. The two ends of the 
piece of cotton are then frayed out until the center of the 
cotton is thicker than the edges. The cotton is then folded 
through its central thick portion, so that the thin edges are 
brought together and a wedge is thus formed, one edge 
being very thick and the other thin. This wedge is now 



DISEASES OF 11 IE EXTERNAL EAR 



343 



vvrapjXid somewhat firmly about the end of an Allen's ear 
probe (Fii^. 199), the thick edge of the cotton wedge toward 
the handle of the instrument in such a manner that the 
thin edge of the cotton wedge forms the pointed end of 
the cone. Th.c cone thus made should be firmly enough 
wrapped about the probe to be smooth and taper evenly 




Fig. 198. — Method of wrapping cotton about the end of an Allen's probe to form a brush 
for cleansing the canal, applying pigments, etc. 

from apex to base. When made it is coated thickly with 
the appropriate ointment and inserted gently into the canal 
until its wedge-like pressure begins to cause pain. The 
probe is then dislodged from the cone by turning it in the 
opposite direction to that in which the cotton was wrapped 
about it and steadying the cone with a touch of the left 




Fig. 199. — Method of wrapping cotton about the end of an Allen's probe so as to form 
a cone for applying pressure within the auditory canal. A piece of absorbent cotton is 
frayed out to thin edges, folded through the center (dotted line a), and wrapped about the 
end of the probe. 



forefinger so that the cone is not withdrawn from the canal 
with the probe. If after a "few moments the pressure of 
the cone instead of affording relief causes increased pain, 
the patient can withdraw it slightly and after an interval 
again push it more deeply into the canal. 

Some relief from pain follows the application of a 10 per 
cent, ointment of cocain in lanolin or a i per cent, ointment 



344 DISEASES OF THE NOSE, THROAT, AND EAR 

of atropin. Heat, however, generally gives speedy relief 
from pain. It may be applied by gently syringing the canal 
with hot water, by the application of a poultice, or by 
resting the head upon a hot-water bag or a bag of hot salt 
or of hops. In severe cases it is advisable to secure a free 
evacuation of the bowels by means of small, frequently 
repeated doses of calomel and bicarbonate of sodium ; 
I -drop doses of tincture of aconite-root, repeated every 
hour, will control to a certain extent fever and pain. In all 
cases the cause of the attack should carefully be sought and 
measures adopted to prevent a recurrence. To prevent 
inoculation of other parts of the canal and producing a 
so-called crop of boils, the canal should be carefully cleansed 
either by syringing gently each day with a warm i : looo 
bichlorid solution or by simply wiping out the pus with 
absorbent cotton and afterward sterilizing the skin of the 
canal by painting it with nitrate of silver solution (3j to fsj 
of w^ater). 

Otitis Externa Diffusa Acuta. — Diffuse inflammation of 
the auditory canal varies in character from a simple erythema 
of the skin of the auditory canal to severe periostitis. The 
disease usually attacks the osseous portion of the canal, 
but it may extend to the auricle, and, by periosteal conti- 
nuity, to the periauricular and mastoid regions, causing 
abscess and necrosis. 

Etiology. — The disease usually occurs in persons w^hose 
general health is impaired. It is sometimes consecutive to 
an attack of otitis media acuta or it may be caused by 
an irritating discharge from the middle ear. The affection, 
which usually begins in the skin or cellular tissue, may 
extend to the periosteum and bone. 

Symptoms. — The symptoms are similar to those of fu- 
runcle of the auditory canal, except that the pain is usually 
more intense and appears at an earlier stage of the disease, 
while deafness and tinnitus are more marked and long con- 
tinued. On inspection the tissues of the auditory canal 
appear red and swollen. The swelling is usually greatest 
in the bony portion of the canal, where it may be so great 
as to completely obliterate the canal and prevent a view of 
the drum-head from being obtained. Generally the skin is 



DISEASES OE 71/ E EXTEA'NAL EAR 345 

excoriated lit points where the innaniination is greatest, and 
usually there is desquamation and a slight watery dis- 
charge. 

Treatment. — Incision of the swollen tissues is rarely 
necessary unless an abscess has formed. Pain can generally 
be alleviated very much, if the case is seen early, by the 
application of a large leech to the skin in front of the 
tip of the mastoid, as closely as possible beneath the audi- 
tory canal. A leech also may be applied in front of the 
tragus and one on the mastoid, as close to the canal as 
possible. 

In many cases it will be necessary to prescribe morphin to 
completely control the pain and secure sleep; but Jicat, 
applied in the manner already described, will be all that is 
necessary in the majority of instances. The canal should 
be cleansed and carefully dried with absorbent cotton and 
the parts painted with a 60-gr. solution of nitrate of 
silver and dusted with powdered calomel. This should be 
done every day as long as the symptoms are acute, and 
afterward, as the disease subsides, at longer intervals. In 
using an insoluble powder like calomel within the canal 
care should be exercised not to more than lightly cover the 
skin and not employ a quantity sufficient to form a hard 
crust, which by its pressure will cause pain. 

Otitis externa diffusa chronica occurs in individuals whose 
health- is impaired, or it may be the result of the gouty or 
rheumatic diathesis, or the irritation caused by carious teeth, 
or disease of the nose and throat. The growth of Asper- 
gillus within the inflamed canal may be a compHcation or a 
cause of disease. 

Symptoms. — Patients complain of itching and a sense of 
heat within the canal. Pain is usually absent, except dur- 
ing acute exacerbations. Upon inspection the skin of the 
auditory canal is found to be red and swollen, especially in 
the deeper portions. The inflammation may be of the 
eczematous or desquamative type and accompanied by a 
watery discharge or seborrhea. 

Treatment. — The cause of the affection should be care- 
fully sought. Patients of the strumous diathesis or in feeble 
health will require the administration of cod-liver oil and 



346 DISEASES OF THE NOSE, THROAT, AND EAR 

tonics, and appropriate remedies should be prescribed for 
those in whom the disease seems to be the result of the 
rheumatic or gouty diathesis. If carious teeth are present 
they should receive the attention of a skilful dentist, and 
any disease of the nose or throat that may be present 
should be properly treated. The local treatment of chronic 
diffuse inflammation of the external auditory canal varies 
according to the stage and variety of the disease present. 
When the disease is of the eczematous type, all scales and 
scabs should be removed by means of a pledget of absorbent 
cotton wrapped about a probe and dipped into a solution 
of the peroxid of hydrogen and yellow oxid of mercury 




Fig. 200.— a, Aspergillus glaucus : B, Aspergillus niger ; C, ripe fructiferous head of Asper- 
gillus niger throwing off spores (Burnett). 

ointment (Formula 41), well rubbed into the parts. When 
there is considerable secretion of watery fluid the canal 
should be dried thoroughly and brushed with a solution of 
nitrate of silver (60 gr. to I ounce of water) and covered 
with powdered calomel. 

Mycosis or otomycosis is an inflammation of the external 
auditory canal due to the presence of a fungus. Asper- 
gillus glaucus (Fig. 200, a) and Aspergillus niger (Fig. 200, 
B, c) are the varieties most frequently met with. The pres- 
ence of moulds in chronic inflammation of the external 
auditory canal may be the cause of the inflammation or only 
a complication of the disease. 

The symptoms are those of an acute or chronic inflam- 



DISEASES OF THE EXTERNAL EAR 347 

mation of the canal, except that when there is a large mass 
of mould present filling the fundus of the canal the patient 
will be deaf from the accumulation. This is usually a 
pasty, whitish material interspersed with black spots, 
looking not unlike a wad of wet newspaper. The micro- 
scope will detect the presence of either or both the Asper- 
gillus glaucus or niger or some other species of Aspergillus 
or Mucor. 

Treatment. — When Aspergillus is present, the canal 
should be cleansed thoroughly each day with peroxid of 
hydrogen and an application made of a 60-gr. solution of 
nitrate of silver or of absolute alcohol. It is essential that 
the canal should at all times be kept absolutely dry, because 
nothing more favors the growth of Aspergillus than 
moisture. Discharges should be absorbed by the applica- 
tion of powdered boracic acid or a mixture of powdered 
boracic acid and aristol. 

Otitis Externa Diphtheritica. — Diphtheritic inflammation of 
the integument of the external auditory canal is an inflamma- 
tion characterized by the presence of a pseudomembrane, 
which when removed leaves a bleeding surface. The pseudo- 
membrane should contain the Klebs-Lofifler bacillus 
characteristic of true diphtheria, as other bacteria are 
capable of causing a pseudomembrane within the auditory 
canal and upon mucous surfaces. 

Etiology. — The disease occurs usually as a complication 
of diphtheria of the throat and middle ear. Primary diph- 
theria of the walls of the external auditory canal has been 
observed during epidemics of diphtheria. 

Symptoms. — In the primary form there are deafness and 
tinnitus, with pain. The meatus is greatly swollen. The 
lymphatics at the angle of the jaw are also swollen and 
tender to the touch. There is usually systemic depression 
and slight elevation of temperature. Examination discloses 
the pseudomembrane covering the swollen skin and bathed 
in discharges, so that the canal is nearly occluded, or, if the 
disease has occurred in a case where the drum-head has 
been previously destroyed, only the mucous membrane of 
the tympanum may be occupied by the diphtheritic mem- 
brane. 



348 DISEASES OF THE NOSE, THROAT, AND EAR 

The secondary form of the disease sometimes causes de- 
struction of the membrana tympani and the tympanic con- 
tents. Occasionally, as in scarlet fever, necrosis of portions 
of the temporal bone occurs. 

Treatment. — The canal should be syringed with a warm 
bichlorid solution (i : looo). The pseudomembrane should 
then be removed with the forceps and peroxid of hydrogen. 
After the parts have been cleansed of membrane they are 
dried with absorbent cotton and painted with a 6o-gr. 
solution of nitrate of silver in water and covered with a 
thick coating of boric acid. 

Pepsin, trypsin, caroid, and other substances will dissolve 
the pseudomembrane, but their use is not desirable in the 
ear because the pseudomembrane soon ceases to re-form 
when the parts are constantly covered by antiseptics. 

Otitis externa crouposa is an acute inflammation of the 
external auditory canal characterized by the presence of a 
pseudomembrane which does not contain the characteristic 
bacilli of diphtheria. 

Diagnosis. — The membrane when removed commonly 
leaves a bleeding surface, as is the case with the pseudo- 
membrane of diphtheria, because croupous membranes rarely 
if ever occur except upon a skin not already excoriated. 

The bacteria are said to be those of a mixed infection, 
usually streptococcus and staphylococcus. 

Symptoms. — The symptoms are practically those of diph- 
theria of the external auditory canal, except that the cer- 
vical glands are rarely as much swollen and inflam.ed. 
There is earache, tinnitus, and a greatly swollen meatus, 
with purulent discharge and, generally, shght fever. 

Treatment is the same as in diphtheritic otitis. The 
pseudomembrane is removed with forceps and peroxid. 
After the parts are dried with absorbent cotton they should 
be thoroughly painted with a 6o-gr. solution of nitrate of 
silver and covered with a thick coating of boric acid by 
means of a reservoir powder-blower. This treatment should 
be repeated once or twice a day. It is probable that after 
two or three applications the pseudomembrane will cease 
to appear, but daily treatment should be persisted in until 
the skin of the canal has assumed a normal appearance. 



CD 




DISEASES OE EIIE EXTERNAL EAR 349 

Exostosis and Hyperostosis (Osteomata). — The name " ex- 
ostosis " was applied formerly to all bony outgrowths within 
the auditory eanal. At the present time, however, the name 
is restricted to bony growths at the junction of the carti- 
laginous and bony portions. Exostoses of the meatus are 
usually single and pedunculated. Hyperostoses are situated 
at the inner end of the meatus close up to the membrane, 
are sessile, and generally multiple (Fig. 201). Both exos- 
toses and hyperostoses are whitish prominences, firm and 
hard when touched with a probe. 

Etiology. — Hyperostoses in most instances are probably 
congenital, and in all cases their presence and growth are 
painless, while an exostosis is 
always preceded by inflammation. V 
A subperiosteal abscess forms 
over the mastoid, the pus finding 
its way into the meatus at the 
junction of the cartilaginous and 
bony portions of the canal. The ^'" ^""'--^T^;'!^^. '^^^^^^ 
mouth of the sinus in this posi- 
tion becomes occupied by exuberant granulations from the 
bone, which become converted into bone. 

Syiuptovis. — Hearing is not impaired unless the bony 
growth or growths are large enough to entirely block the 
lumen of the meatus. The smallest opening is sufficient to 
transmit sound-waves. If, however, such a small opening 
is occluded by a drop of fluid, or by a few scales of epithe- 
lium, or by a small mass of cerumen, the hearing at once is 
grealy impaired. When purulent disease of the middle ear 
is present the presence of hyperostoses will greatly interfere 
with drainage and render the disease difficult to cure. 

Treatment. — If an exostosis is large and attached by a 
rather small pedicle to the auditory canal, especially if the 
growth be slightly movable, it can readily be detached by 
means of a small chisel and extracted wath a pair of forceps. 
Exostoses of this character should always be removed. 

Occasionally sessile exostoses are encountered that extend 
the whole length of the bony canal and encroach upon the 
position of the drum-head. Under such circumstances it is 
best to secure additional room for the necessary chiseling 



350 DISEASES OF THE NOSE, THROAT, AND EAR 

by detaching the auricle and cartilaginous canal and pushing 
it forward out of the way in the same manner as in the 
radical mastoid operation. The bony canal should be en- 
larged by the removal of rather more bone than that com- 
prising the exostosis, in order to provide for cicatricial 
contraction during the healing process. If the cartilaginous 
portion of the canal is contracted, it should be slit up and 
the parts adjusted in position in the same manner as after a 
radical mastoid or Stacke operation. The more superficial 
parts of the exostosis are very readily removed by a suitable 
gouge or chisel ; but when the neighborhood of the drum- 
head is reached it is well to employ a dental burr if the 
bone is found to lie closely in contact with the drum-head. 

Hyperostoses are best let alone, even in those cases in 
which they encroach upon the canal to such an extent as to 
decrease greatly its lumen. If from time to time the patient 
becomes deaf from an accumulation of cerumen between 
the hyperostoses, this should be picked carefully away by 
means of an appropriate instrument. The syringe should not 
be used unless absolutely necessary, because it is often difficult 
to remove fluid from behind the exostoses after syringing, 
and it may be the cause of an inflammation of the auditory 
canal and drum-head exceedingly difficult to control. Where 
the presence of hyperostoses seriously interferes with proper 
drainage in cases of purulent otitis an attempt should be 
made to effect a removal of one or more of the growths by 
means of a drill propelled by an electric motor. 

Foreign Bodies. — Animate and inanimate objects, impacted 
cerumen, and laminated epithelial plugs are found in the 
auditory canal. 

Animate objects that may enter the auditory canal are flies 
and other insects, the larvae of insects, and various moulds. 

The treatment when the auditory canal is invaded by a 
growth of Aspergillus, Mucor, or other moulds has already 
been detailed (p. 347). Insects can generally be removed 
readily by means of the syringe. The larvae of insects are 
not usually present unless there be suppuration of the mid- 
dle ear, but cases have been reported of the presence of 
maggots within the auditory canal when the drum-head was 
intact and no suppuration existed. Larvae can be killed 



DISEASES OE THE EXTERNAL EAR 35 1 

with chloroform vapor and then removed by means of the 
syringe. 

It is not permissible to drop chloroform into the auditory 
canal as a blister may result. A part of a drop may be ab- 
sorbed by a small amount of cotton, which in turn is sur- 
rounded by sufficient cotton to make the plug fit snugly 
into the canal. Used in this manner the chloroform evapo- 
nites from the cotton into the canal, and the vapor produces 
a sensation of warmth and comfort. However, if, after a 
few moments, the application becomes painful it indicates 
that the chloroform vapor has penetrated the auditory canal 
in too large an amount, and the plug of cotton should be 
loosened or withdrawn from the canal entirely for a few 
moments, and then, if necessary, reinserted. 

Generally the pain caused by the movements of the 
insects ceases within a few seconds after the use of the chloro- 
form vapor and the insect may then be removed by syring- 
ing or, if necessary, with the forceps. In the case of ants, 
wood-ticks, or other insects that sometimes attach them- 
selves to the canal or the drumhead by their strong mandi- 
bles or jaws the death of the insect is not always followed 
by a release of its hold upon the tissues. Under such cir- 
cumstances the dead body of the insect can be removed by 
a pair of forceps. In the case of the wood-tick a portion of 
the tissue to which it has attached itself may be drawn out 
with the insect. This is a matter of no great consequence 
when the insect has attached itself to a portion of the canal ; 
but irreparable mischief might be done by ill-considered 
efforts at removal when the insect has attached itself to the 
drum-head. In cases where, because of the nervousness of 
the patient or swelling of the canal, it is impossible at once 
to remove an insect that has been chloroformed, the canal 
should be filled with fluid vaselin or some other bland oil to 
prevent the resuscitation of the insect should the amount 
of chloroform vapor have proved insufficient to have caused 
its death. 

Inanimate Objects. — Shoe-buttons, pebbles, glass beads, 
the ends of lead- and slate-pencils, and other objects are 
sometimes placed by children within their ears in a spirit of 
mischief. It is not rare for aurists to find parts of an onion 



352 DISEASES OF THE NOSE, THROAT, AND EAR 

or pieces of cotton that were placed within the auditory 
canal by patients perhaps months or years before and for- 
gotten. The writer removed from an old gentleman's ear 
three little wads of cotton which had been placed there 
several years before when he was treating himself for what 
he stated was " a boil in his ear." On one occasion, having 
demonstrated the removal of a foreign body from the ear 
of a dispensary patient before a ward class of ten or twelve 
senior students, the WTiter was requested by one of these 
students to examine his ear as he thought he had got sand 
in it while bathing at Atlantic City the previous summer. 
There was removed not only a small amount of sand but 
also a cherry stone, shrunken and black from age, which 
the student stated he dimly remembered having placed in 
his ear when a child. From the ear of another member of 
this same class was removed a small wad of cotton which 
the student stated must have been placed there the winter 
before. 

These stories are worth relating, as they illustrate how 
little annoyance foreign bodies in the ear sometimes cause. 
On the other hand, impacted cerumen and other foreign 
bodies are said to have been the cause of persistent cough, 
nausea, and even epilepsy. As some sensitive patients 
cough almost continually while their ear is being cleansed 
and more especially when the floor of the canal at the junc- 
tion of the cartilaginous and bony portion is rubbed with a 
probe, while others become faint and nauseated under simi- 
lar circumstances, it readily is understood how in a neu- 
rotic or hysteric individual the presence of a foreign body 
in the ear might be the cause of such unusual s)miptoms. 

Among the foreign bodies may be classed impacted ceru- 
men and laminated epithelial plugs. 

Removal of Foreign Bodies. — Leaves of the onion, wads of 
cotton, and other soft objects are readily grasped by mouse- 
toothed forceps and extracted. Hard, round objects, such 
as shoe-buttons and glass beads, should at first be attacked 
by means of a syringe. A fine cannula should be placed 
in such a position that a stream of fluid can be thrown into 
the auditory canal past the object. If careful syringing in 
this manner fails to dislodge the foreign body, a delicate 



DISEASES OF 771 E EXTERNAL EAR 353 

hook, made by bending the end of an Allen's probe at a 
right angle (^hig. 202), should be introduced into the canal 
between its wall and the object, and an effort made to ro// 
the object cnitward through the canal. I lard, irregularly 
shaped bodies that cannot be rolled out with a hook or 
grasped by the forceps will often tax the ingenuity of the 
surgeon to effect their removal. In such cases strong cement 
or glue may be smeared on the outer surface of the foreign 
body and then a small mass of cotton applied. After a day or 
two, when the cotton is firmly attached to the foreign bod}', 
the cotton can be grasped with forceps and the foreign body 
removed. 

Efforts at removal of foreign bodies should always be 
made with extreme gentleness, for fear of injuring the drum- 
head, and the surgeon should bear in mind that rather than 
incur the risk of doing so it is preferable to detach the auri- 
cle from the bony meatus by means of an incision made 



Fig. 202. — Allen's probe bent to hook cerumen, etc. 

posterior to the auricle, and turn the auricle and cartilag- 
inous meatus forward upon the cheek. 

In children it is generally necessary to give an anesthetic 
to secure that perfect quiescence of the patient necessary 
for the delicate and careful manipulation of instruments. In 
difficult cases it is best not to prolong unsuccessful efforts 
to remove a foreign body, for often it will remain in the audi- 
tory canal for years without producing any serious symptoms. 
In cases where it has been impossible to remove the foreign 
body at the first sitting, time should be given for the inflam- 
mation to subside, and after all swelling of the auditory 
canal has subsided efforts for the extraction of the foreign 
body will finally prove successful. Seeds and other objects 
that have swollen by the absorption of w^ater may be dehy- 
drated and shrunken by the instillation of alcohol. 

Cases in which the uninitiated, by injudicious and unsuc- 
cessful efforts to remove a foreign body, have ruptured the 
drum-membrane and caused acute purulent inflammation 
23 



354 I^ISEASES OF THE NOSE, THROAT, AND EAR 

of the middle ear, and in which so much sweUing of the 
canal has arisen that nothing can be seen, should be treated 
by frequent syringings with warm water and by the use of 
a hot-water bag, if necessary, to relieve pain until the inflam- 
matory symptoms have subsided and the foreign body can 
be seen. No attempt at its removal should be made until 
swelling has subsided and the speculum can be used with- 
out causing pain. 

Impacted Cerumen. — Subjective Symptoms. — There usu- 
ally is a sense of fulness and itching, and the patient com- 
plains that he has suddenly become deaf in one ear without 
any previous symptoms of inflammation. The explanation 
of this fact is that so long as there is the smallest conceivable 
opening through a mass of cerumen it will be sufficient to 
transmit sound-waves and the hearing will not be greatly 
impaired. Sometimes a small opening through a mass of 
cerumen will close from time to time during damp weather 
and open again when the atmosphere becomes dry. This 
phenomena may be repeated many times, the patient being 
deaf only during damp \veather. Even when impacted ceru- 
men is present in both auditory canals the patient usually be- 
comes deaf in one ear first. Under such circumstances the 
larger amount of inpissated cerumen may be removed from 
the ear in which the hearing is the most nearly perfect ; 
sometimes after the patient has protested that " there is 
nothing the matter with that ear." 

Etiology. — Increased secretion of cerumen is usually the 
result of disease of the middle ear or of catarrh of the 
nose and throat. It is rather unusual to find the hearing 
perfect after the removal of a mass of impacted cerumen. 
The introduction of irritants within the auditory canal 
increases the secretion of cerumen. 

This is true of dusty employments, like coal-mining, 
stoking, or milling. Under such circumstances the mass 
of cerumen removed may consist partly of coal-dust or 
flour introduced into the canal by the dirty fingers of the 
workman while endeavoring to relieve the irritation of 
the canal by scratching it. Impactions result from ill- 
advised efforts to cleanse the canal by inserting into it the 
screwed-up corner of a towel or the clumsy use of a match- 



D/SKASKS OF THE EXTERNAL EAR 355 

stick or car-spoon. When such articles are used dead 
epithehal scales and inspissated cerumen are thrust deep into 
the canal, which, if left to themselves, would have scaled 
off or exfoliated and dropped out of the canal. Hence the 
well-known saying that has come down to us from the 
aurists of half a century or more a[(o, '* An individual 
should not put into his own ear any instrument smaller 
than his elbow." 

Trcatnioit. — If the mass be soft, syrin^^ing with warm 
water will cpiickly remove it, inspissated cerumen being 
soluble in water. If, however, the accumulation is very 
hard and dry and is mixed with a considerable proportion 
of epithelial scales, the mass may be softened by directing 
the patient to fill the canal with warm water several times a 
day before efforts at removing the mass are attempted. This 
plan is probably advisable for those who have had little 
experience with the manipulation of instruments within the 
auditory canal. Although inspissated cerumen is perhaps 
as readily soluble in water as any other bland fluid except 
peroxid of hydrogen, olive oil or a mixture of water, 
glycerin, and bicarbonate of sodium (20 gr. to I ounce) is 
sometimes prescribed, to be dropped into the ear several 
times a day, to soften inspissated cerumen before efforts are 
made to extract the mass by syringing. 

However, it should be borne in mind that the hearing 
will be temporarily impaired as the result of dropping any 
fluid into the auditory canal when it contains a considerable 
quantity of cerumen, for reasons stated above. After the 
lapse of a few hours the wax may in rare instances have 
been increased in bulk sufficiently to cause pressure pain. 
When the surgeon is sufficiently expert with hook and 
syringe, it is never necessary to employ any fluid to soften 
the cerumen, the removal of the hardest and largest 
specimens being the work of only a few moments. 

When the impacted cerumen is very hard and firmly 
fixed w^ithin the auditory canal it is probably best not to 
attempt to remove it by syringing until the mass has been 
rendered movable by manipulation with instruments. For 
this purpose the tip of an Allen steel probe, bent at a right 
angle (Fig. 202), should be introduced flatwise between the 



356 DISEASES OE THE NOSE, THROAT, AND EAR 

wall of the canal and the cerumen until it has penetrated a 
short distance, when the hook should be turned into the 
mass of cerumen and gentle traction exerted. Generally 
there will be detached a small portion of the impacted 
cerumen, which can easily be removed from the canal. 
Proceeding carefully in this manner, it is sometimes possible 
to remove, even in those cases in which the wall of the canal 
is very sensitive, the entire mass of impacted cerumen 
without causing even the slightest pain or congestion of the 




Fig. 203. — Washing impacted cerumen from canal. Showing how to hold auricle to 
straighten canal and where to direct the stream of water. 

drum-head, the procedure being v^astly less disagreeable to 
the patient than syringing. However, it is best in many 
instances to desist as soon as the mass of cerumen is felt to 
be movable and resort to the syringe. The syringe used 
by dentists to cleanse carious cavities in teeth (Fig. 38, c, 
with nozzle 8) is an admirable instrument for syringing ceru- 
men from the ear. The stream of fluid should be thrown be- 
hind the impacted cerumen through the opening that has 
been made by an instrument (Fig. 203). One or two syringe- 
fuls of warm water will probably suffice to remove the greater 



DISEASES OF THE EXTERNAL EAR 



357 



portion of the cerumen, after wliicli the auditory canal 
should carefully be cleansed of any remaininf^ flakes by a 
dossil of absorbent cotton wrapped about the end of an 
Allen probe and dipped into a solution of peroxid of 
hydrogen. 

A metal ear-spout (Fig. 204'j will be found convenient to 
receive the fluid from the auditory canal during the syring- 
ing. It should be borne in mind that .syringing an ear is at 
best a disagreeable procedure, and that the 
injection of water either too cold or too hot 
or with too much force into the auditory 
canal is usually followed by syncope. The 
writer once saw in the dispensary a patient 
drop from the stool on which he was seated 
as suddenly as if he were shot. A student 
was attempting to remove impacted cerumen 
by syringing, and had inadvertently injected 
cold water into the patient's ear with con- 
siderable force. Where the quantity of 
cerumen is so large that it is impossible for 
the first syringeful to reach the drum-head, 
it is justifiable to inject with considerable 
force, but as the tympanum is approached 
judicious gentleness should be employed. 
Especially where the drum-head is lacking, 
syringing the ear may be made absolutely intolerable by 
want of gentleness and judgment on the part of the operator. 

Keratosis Obturans or Epithelial Plug.— The name " kera- 
tosis obturans " was applied by Weeden of St. Petersburg 
to epithelial lamina impacted within the auditory canal in 
contradistinction to "cerumenosis obturans " or impacted 
cerumen. In masses of impacted cerumen there are more 
or less epithelial laminae. However, the typic laminated 
epithelial plug consists almost entirely of laminae of epithe- 
lium packed one about the other. The external end of 
such a mass is generally covered by inspissated cerumen 
which, of course, is easily removed by syringing when the 
laminae of closely packed epithelial scales are exposed to 
view, looking not unlike a plug of wet chamois skin. It is 
impossible to remove such an accumulation by syringing. 




Fig. 204.— Metal 
ear-spout. 



358 DISEASES OF THE NOSE, THROAT, AND EAR 

It is necessary to effect its removal layer by layer by means 
of a hook, a curet, or by forceps. A laminated epithelial 
plug is composed of the horny layer of the cutis of the 
auditory canal, which accumulates, layer by layer, within 
the canal as the result of desquamative inflammation. After 
the removal of a laminated epithelial plug the membrana 
tympani will probably be found normal in appearance and 
the hearing be perfect. Usually this is not the case when 
the collection within the canal consists, of a cholesteato- 
matous mass. 

Aural Cholesteatoma. — The name " aural cholesteatoma " 
is sometimes applied to a true new growth within the tem- 
poral bone, similar to cholesteatomata found in other bones 
of the skull. Ordinarily, " cholesteatomatous mass " means 
an accumulation within the auditory canal and tympanum 
of a mass consisting of epithelial scales, cholesterin crystals, 
and inspissated pus, derived by desquamative inflammation 
from the Hning membrane of the tympanum or mastoid 
cells. 

The presence of cholesteatomatous masses usually 
causes impaired hearing, tinnitus, and sometimes nausea and 
dizziness. The bony and soft structures often become 
absorbed as the result of the pressure caused by the accumu- 
lation of cholesteatomatous material, so that cholestea- 
tomatous accumulations are sometimes found occupying 
large cavities — so large, indeed, that in one instance the 
cavity from which a cholesteatoma was removed involved 
the greater part of the auditory canal, the whole of the 
tympanum, and a large part of the mastoid and petrous 
portion of the temporal bone. 

Small collections of cholesteatomatous material are com- 
mon at the upper and posterior portion of the auditory 
canal in cases in which perforation of Shrapnell's membrane 
has occurred. The mass often extends into the attic of the 
tympanum, sometimes into the mastoid antrum. Choles- 
teatomatous masses are usually not easily detected at the 
first glance. Sometimes a small mass projecting into the 
meatus will be the only evidence of the presence of a cho- 
lesteatoma of considerable size. If, however, the small 
mass projecting into the canal be removed, other masses 



DISEASES OE THE EXTERxWAL EAR 359 

will bo foiincl, until in sonic instances a cavity of consider- 
able size will have been emptied of its contents. The 
beginner in otology should be on the lookout for accumu- 
lations of this kind and should not consider his otoscopy 
completed until all visible parts have received the closest 
scrutiny and been thoroughly cleansed. 

Etiology. — When the membrana tympani is perforated as 
the result of disease or operative interference the opening 
in the drum-head generally promptly closes. If, however, 
a large pt)rtion of the drum-head is destroyed as the result 
of long-continued suppuration, the epidermis of the canal 
proliferates over the margins of the perforation and prevents 
its being filled by granulations ; so that the perforation 
tends to become permanent. Furthermore, under certain 
conditions the epidermis of the canal proliferates over the 
walls of the cavities of the middle ear, and a greater or 
lass extent of surface assumes a skin-like character and 
appearance. The entire tympanum, aditus and antrum, may 
become epidermized, but generally the epidermis extends 
but a short distance into the tympanum. 

When the attic and antrum become epidermized their 
lining membrane exfoliates as the result of chronic inflam- 
mation, and epidermic scales unless removed accumulate 
until the entire cavities become filled, as shown in Figs. 

233, 234. 

Occasionally the presence of a small collection of choles- 
teatomatous material in the attic will cause a small amount of 
discharge through a fistula over the drum-head, and this 
scanty discharge, drying almost as it is secreted, sometimes 
forms closely adherent casts of the drum-head that might 
easily be mistaken for the drum-head itself. The removal 
of such casts from the drum-head is generally followed by 
considerable improvement in the hearing. 

Although Toynbee refers to collections of cholesteato- 
matous material under the name of " pearly or molluscous 
tumors," and evidently thought that they were derived from 
the epidermis of the auditory canal, and Hinton, Kupper, 
and Wendt refer to similar collections derived from the epi- 
dermis of the drum-head, yet the majority of authors who 
wrote previous to the last decades taught that cholesteato- 



360 DISEASES OF THE NOSE, THROAT, AND EAR 

mata were due to the retention of the products of inflam- 
mation of mucous membranes. The fact that cholestea- 
tomata are not infrequently found within the middle ear 
when the drum-head is intact and there is no communication 
between the auditory canal and the cavity containing the 
mass seemed to favor this view, but it should be borne in 
mind that perforations of the drum-head may persist for 
years and finally close. 

DISEASES OF THE MIDDLE EAR 



THE MEMBRANA TYMPANI 

When inspecting those parts of the ear visible by otos- 
copy the attention of the observer should be particularly 
directed to the size oi the auditory canal and the condition 
of its wall. Every little scale of epidermis or mass of ceru- 
men that can possibly hide an abnormal condition should 

carefully be removed by 
means of a cotton-tipped 
probe. The observer's eye 
should next seek the umbo 
or depression near the cen- 
ter of the drum-head, and 
the glance should then be 
directed upward along the 
handle of the malleus until 
Shrapnell's membrane is 
brought into view. This 
portion of the membrane 
should receive the most 
careful scrutiny, an effort 
being made to discover, if 
possible, the presence of the so-called foramen of Rivini or 
anything abnormal in this region. Attention should next 
be directed to the condition of the anterior and posterior 
folds, after which the glance of the observer should be 
directed around the periphery of the drum-head. By ob- 
serving always this or some other definite plan of examina- 
tion during otoscopy it will hardly be possible that any 
abnormal condition of importance will escape observation. 




Fig. 205. 



-Foreign-body and polyp forceps 
(after Hartmann). 



DISEASES OF Till': MIDDLE KAR 



361 



Particular attention should be directed to the size, shape, 
and position of the cone of ligiit, the apparent len<^th and 
position of the malleus handle, and the dei^ree of promi- 
nence of the short process; the color, lustre, apparent 
thickness, curvature, and position of the drum-head; as 
well as the presence or absence of perforations, cicatrices, 
chalk deposits, localized spots of atrophy or thickening, 
polypi, abscesses, exudation-cysts, or other pathologic con- 
ditions. 

Changes Occurring in the Curvature of the Membrana Tym- 
pani. — The membrana may bulge outward as the result of 
pressure from fluid within the tympanum or there may be a 




Fig. 206. — Politzer's ear forceps. 



localized " pointing " of pus at any position on the drum- 
head. The normal curvature of the drum-membrane 
depends largely upon the tension of the tensor tympani 
muscle. It is claimed that the rectractile effect of this 
muscle is increased after death by rigor mortis and in certain 
conditions the muscle is constantly contracted during life to 
an extreme degree. 

An unduly depressed condition of the membrana tym.- 
pani also occurs as the result of unequal pneumatic pressure 
upon its two surfaces, when obstruction of the Eustachian 
tube interferes with the proper ventilation of the tympanic 
cavity. Sometimes the retraction of the membrane is quite 
abrupt at points near the periphery, so that a sort of terrace 
is formed at that point. Under such circumstances a bright 



362 DISEASES OF THE NOSE, THROAT, AND EAR 

line will be seen at the point where the abrupt change of 
curvature occurs. Should such an abrupt change of cur- 
vature occur at the position of the cone of light it will 
appear as if broken transversely into two parts, that nearest 
the periphery assuming a crescentic shape. Whenever the 
membrane is retracted as a whole there is usually some 
change in the Hght spot. It often loses the triangular 
form, because of which it has received the name " cone " 
or " pyramid of light," and becomes narrow, reduced to a 
mere point, or perhaps entirely disappears. 

The posterior fold becomes large and prominent when the 
drum-membrane is greatly retracted and the malleus handle 




Fig. 207. — Retracted membrane of a girl 
of ten years, with long-standing nasal and 
tubal obstruction, showing foreshortening of 
malleus handle, prominence of the posterior 
fold, and visibility of the margin of the 
pocket of von Troelsch as it passes forward 
to the manubrium. The light spot is short- 
ened, and beyond it anteriorly are two 
parallel curvilinear bright lines, marking the 
edges of abruptly depre.ssed areas of the 
drum-head, one within the other (Randall). 




Fig. 208. — Left membrana tympani of a 
boy of six years, with nasal and tubal ob- 
struction. Manubrium drawn up almost out 
of sight, the tip being higher than the short 
process; behind it the incudostapedial joint 
is visible, and below and posteriorly the dark 
niche of the round window is discernible. 
There is a faint reflection of light near the 
normal position, and a stronger one on the 
promontory near the stapes (Randall). 



foreshortened (Fig. 207) or displaced, usually backward 
(Fig. 208). The two diagrams (Figs. 209, 210) represent 
the means by which the apparent shortening of the malleus 
handle is produced. 

Myringitis is an inflammation of the membrana tympani, 



characterized by 



swellinp;, and sometimes 



ulceration of the membrana tympani, pain, and tinnitus ; but 
hearing is not greatly impaired unless the inflammation also 
involves the entire tympanic cavity. The pain is increased 
by movements of the jaw, pressure in front of the tragus, 
or traction upon the auricle ; it is generally shooting rather 
than throbbing in character. 

Etiology. — The commonest cause of myringitis is 



ex- 



DISEASES OE rilE MIDDLE EAR 



36: 



posurc to cold, especially the direct impact of a cold wind 
upon the membrana tympani in persons whose auditory 
meatus is unduly open. It is sometimes the result of direct 
violence, as, for example, a blow upon the auricle or the 
impact of a wave in surf-bathin^^. In some cases the etioloL,^y 
is obscure and the disease seems to be the result of struma 
or of the rheumatic or gouty diathesis. 

Symptoms. — Severe pain, shooting in character, tinnitus, 
and more or less deafness. Upon inspection, if the disease 
is seen in its earlier stages, the membrane will be found 
markedly congested at the periphery and behind the malleus 
handle. Large vessels will be seen in these positions and 
radiatinir branches will extend from the blood-vessels behind 




Fig. 209. — Diagram of the normal posi- Fig. 210. — Diagram of a retracted mem- 

tion of the malleus and membrana tympani. biana tympani, showing the malleus handle 
The apparent length of the malleus handle drawn backward imtil its tip is in contact 
to the eye of an observer is represented by with the promontory. Ihe apparent length 
the distance a-b. of the malleus handle to the eye of an ob- 

server is represented by the distance a-c, 
the apparent length of the malleus handle 
having been "foreshortened" about one- 
half. 

the malleus handle to inosculate with those coming from 
the periphery. The surface of the membrane becomes lus- 
treless and rough from loosening of its epithelium, and thick 
and opaque and of a uniform reddish color from infiltration 
and increased congestion, until all landmarks except the 
short process of the malleus handle are hidden from view, 
this too finally disappearing beneath the swelling, the mem- 
brane being, at this stage of the disease, of a lively red color 
and apparently either flat or actually convex in form. As 
the integument in the neighborhood of the drum-head is 
also congested it is difficult to make out its boundaries, 



364 DISEASES OF THE NOSE, THROAT, AND EAR 

the red and convex membrane appearing not unlike a poly- 
pus projecting into the canal, for which it has been mistaken. 
In the course of the disease the epidermis exfoliates, 
wholly or partly, and there appears ah abundant secretion, 
which is at first serosanguineous, but later becomes purulent. 
Exudation-cysts, filled with serum or pus, sometimes appear 
upon the surface of the drum-head. Pressure with a probe 
will indent such collections of fluid between the layers of the 
drum-head and the indentation will remain visible for some 
time (Fig. 21 1), which is not the case in localized pointings 
of pus from within the tympanum. If abscesses rupture or 
are incised, ulcers result, which may either heal or perforate 
the drum-head. 

As the inflammation subsides the portion of the membrane 
at the umbo is the first to resume its normal appearance. 
The periphery of the drum-head and a 
triangular portion, whose base includes 
Shrapnell's membrane and whose apex 
is at the tip of the malleus handle, re- 
main red and swollen for some days. 
Finally the swelling and congestion dis- 
appear from these parts of the mem- 
brane, the light spot becomes distinct, 
, , „ and the drum-head assumes its normal 

Fig. 211 . — Interlamellar 
abscesses of right membrana appCaranCC. 

;^"Te'pSTatelTy Rclapscs arc not infrequent or an 
KrarfLrn^twn^and Hcutcattack may assumc the chronic 

forward (Schwartze). form of thc disCaSC. 

Treatment. — In acute cases pain may 
be relieved by the application of leeches and afterward by 
the use of hot fomentations. When a discharge appears 
the parts should be thoroughly cleansed by means of a 
dossil of cotton dipped into peroxid of hydrogen and 
the membrane should be covered with a thin coating of 
powdered boric aid. In traumatic cases the pain and con- 
gestion rapidly subside under i-drop doses of tincture of 
aconite-root administered every hour. A 4 per cent, solu- 
tion of cocain should meanwhile also be dropped into the 
auditory canal sufficiently often to keep the parts moist- 
ened until the pain subsides. 




DISEASES OE THE MIDDLE EAR 365 

Chronic Myringitis. — Chronic inflammation of the drum- 
head is practically always present in chronic otorrhea ori<^- 
inating in the tympanic cavity. In such cases the chronic 
myringitis is part of the intratympanic inflammation and 
generally subsides after the discharge has ceased. The per- 
foration, if not too large, then closes spontaneously or can 
be made to close by one of the methods described in the 
section on Perforations of the Membrana Tympani. 

However, chronic myringitis is occasionally encountered 
without a history of previous middle-ear otorrhea, and then 
generally is part of a chronic inflammation involving at 
least the deeper portion of the auditory canal. 

Etiology. — Gout, rheumatism, or struma may account for 
the cases of chronic myringitis when there is no history of 
a previous otorrhea. Most cases are, however, the heritage 
of a middle-ear suppuration, and in cases where there is a 
scanty fetid discharge in the fundus of the canal it is well 
to inspect the posterior upper quadrant of Shrapnell's mem- 
brane closely for a fistula leading into the attic before being 
satisfied that the drum-head is intact. 

Syniptoins. — The subjective symptoms are a sensation of 
fulness and itching within the ear. As the drum-head has 
little to do with the function of hearing, the hearing in these 
cases is only slightly impaired unless the intratympanic 
structures are involved. There is sometimes a very scanty 
fetid discharge. This discharge adheres to the drum-head 
and collects in small amounts upon the adjacent lower por- 
tion of the canal. When wiped away with cotton and per- 
oxid the drum-head is reddened, either as a whole or in 
spots where the epithelium has exfoliated. Some of these 
areas mark the position where a minute abscess has rup- 
tured and may be covered with granulations or minute 
polypi. In cases where there is no discharge the drum- 
head lacks lustre and is rough from the loosening of its 
epithelium. The color of the drum-head varies according 
to the degree of the inflammation from a dull red to a yel- 
low or dirty white. It is no longer translucent, but is thick 
and opaque. The cone of light is absent or small and dis- 
torted. 

Prognosis. — The course of the disease is slow. Chalk 



366 DISEASES OF THE XOSE, THROAT, AXD EAR 

deposits and areas of localized thickening or atrophy are 
not uncommonly seen when the disease has run its course. 

Treatment. — When chronic myringitis is part of an in- 
flammation of the other anatomic structures of the tympa- 
num the treatment is largely that of the intratympanic 
condition. 

In cases where there is a discJiarge from the dermic sur- 
face of an intact drum-head, this should be cleansed care- 
fully by syringing first with warm water and afterward 
with sublimate solution. The canal should then be dried 
thoroughly by means of absorbent cotton wrapped about 
the end of an Allen's probe and painted with a 60-gr. solu- 
tion of nitrate of silver. 

Abscesses, if present on the drum-head, should be evacu- 
ated and the interior of the abscess touched with nitrate of 
silver by means of a bead of the salt fused on the end of a 
probe. 

Graiudar spots and small polypi upon the drum-head 
should receive special attention. Where the granulations 
are small, simply thoroughly applying at intervals of three 
or four days a 60-gr. solution of silver nitrate is sufficient to 
bring about a cure. When the granulations are larger and 
coarser it will be necessary to destroy them with a 50 per 
cent, solution of chromic acid or by touching them with 
trichloracetic acid. These applications should be made with 
care, so that no dip of acid is allowed to flow or spread be- 
yond the bounds of the granular area. Polypi too small to 
be removed with a snare should be scraped away from their 
place of origin on the membrana by means of Buck's sharp 
curet or removed by means of Hartmann's curet forceps 
(Fig. 205). 

In cases where the- granulations on the drum-head are 
coarse or a small polypus has been removed, the patient 
should be instructed to drop into his ear 95 per cent, alco- 
hol (diluted if necessary) every three hours between his 
visits to the aurist (Formula 49). 

Nitrate of silver in strong solutions was extensively used 
by the aurists of half a century ago as an application to the 
drum-head. Wilde believed that it brought about exfolia- 
tion of the dermic layer of the membrana and thus dimin- 



DISEASES OF THE MIDDLE EAR 367 

ished its thickness. While these views of this distinguished 
Dubhn aurist are not exactly in harmony with modern 
teaching, yet it is probable that the silver oxid deposited 
upon the dermic layer of the drum-head as the result of 
applications of nitrate is partly absorbed by the deeper 
structures, acts as a sedative, and promotes the absorption 
of inflammatory products. 

For cases that result from a rheumatic or gouty diathesis, 
alkalies, with iodid of potassium or salicylate of sodium, 
should be prescribed, while for cases where the disease re- 
sults from struma or debility the use of tonics and cod-liver 
oil and the employment of hygienic measures should be 
advised. 

Deposits of chalk (Fig. 218) are usually the result o{ loug- 
continncd inflaminatioi of the membrana tympani. Their 
presence does not indicate that the patient has the gouty 
diathesis. Only when large do they greatly interfere with 
the acuteness of hearing by stiffening the drum-head and 
interfering with its vibrations. 

Rupture of the drum-head may result from the direct 
impact of a foreign body or from the instruments used in 
extracting a foreign body. Many cases are the result of 
the sudden compression of the air in the auditory canal pro- 
duced by falls or blows upon the ear or the discharge of 
large cannon when the patient occupies a position near the 
mouth of the gun, etc. ; and when the membrane is diseased, 
from the use (abuse) of Politzer's air-douche, Siegle's 
pneumatic speculum (probably the more dangerous instru- 
ment), and even from violently blowing the nose. The 
writer observed a case of this kind in an old lady of about 
seventy, whose drum-head, aside from the usual senile 
changes, so far as could be judged by her history and the 
appearance of the other drum, was normal previous to the 
accident. Another case was that of a robust young man 
who attributed his ruptured drum-head to a kiss on his ear. 

The drum-head may or may not be ruptured in fractures 
of the base of the skull. Even in such cases, where there is 
hemorrhage from the meatus, the blood may come through 
the roof of the canal and the membrana tympani be intact, 
as in a case observed post mortem by the writer. 



DISEASES OE THE NOSE, THROAT, AND EAR 

Injury to the drum-head may result from contrccoup or 
be explained by the irradiation theory of Aran. 

One of the writer's cases, a lad of about sixteen years, 
exhibited rupture of both drum-heads as the result of a blow 
from a baseball received on the left mastoid. It is stated 
that gunshot wounds of the mastoid may cause rupture of 
the drum-head apparently as the result of the jar from the 
impact of the bullet. However, it should be remarked in 
this connection that a hard blow from the bare fist on the 
ear is far less likely to produce rupture of the drum-head 
than a lighter blow from the palm of the hand or a boxing- 
glove, the rupture in the latter case resulting from the 
condensation of air in the canal. 

_ In rupture of the drum-head resulting 

from the concussion of cannon shots, burst- 
ing shells, etc., there is apparently, if one 
may judge by the stellate scars seen in 
cases where the victims have escaped with 
their lives, actually a tearing out of a por- 
tion of the drum-head, usually just below 
the tip of the malleus. 

The subjective symptoms are sudden deaf- 
FiG. 2i2.-Rupture ncss, tinuitus, vertigo, and hemorrhas^e or 

ot the antero-inierior t i r ^ 

half of the drum-head, a scrous dischargc from the ear. 

caused by a box on r^-i , • ^ ,^ , ,• 

the ear (after Poiitzer). 1 Hc pvogHosis as rcgaros tuc rcstoration 

of hearing depends upon the amount of 
damage done to the other structures of the ear. Most 
uncomplicated cases recover satisfactorily and speedily, but 
sometimes purulent inflammation of the middle ear follows 
as the result of the injury or injudicious treatment. 

Treatment. — Cleanse the external auditory canal care- 
fully, so as to remove all blood-clots or other material that 
might favor the growth of bacteria. Use Politzer's air- 
douche if necessary to remove blood from the middle ear 
or little shreds remaining between the edges of the wound 
to retard union ; apply by means of the powder-blower a 
thin layer of boric acid upon the drum-head, and let the 
ear entirely alone until the healing process is complete, un- 
less pain or the appearance of a purulent discharge renders 
further interference necessary. 




diseasp:s of the middle ear 



369 



Perforation of the membrana tympani sometimes occurs 
as the result of ulceration from the dermic surface of the 
drum-head during an attack of acute myrini^itis. Under 
such circumstances the ulcer is usually central. The com- 
monest cause, however, of perforation of the membrane 
is ulceration from within, the result of otitis media puru- 
lenta. 

Syniptcmis. — Examination by means of the concave mirror 
and speculum usually discloses the presence of the perfora- 
tionj which, if large, is readily seen. In most cases inflation 
of the middle ear by the Politzer method produces a char- 
acteristic " perforation whistle," readily heard by means of 
the auscultation-tube (Fig. 189). 
Indeed, the perforation whistle is 
often so loud that it can be heard 
at a distance of many feet from the 
patient. If suppuration of the 
middle ear is present pus will es- 
cape through the perforation in the 
form of bubbles during inflation. 

The subjective symptoms vary 
according to the size and position 
of the perforation and other dis- 
eased conditions of the ear that 
may be present. A perforation 
of Shrapnell's membrane (Fig. 2 1 3), 
when it has been present for some 
time, is usually accompanied by 
considerable hardness of hearing, 
because purulent inflammation of 
the attic, the commonest cause of perforation in Shrapnell's 
membrane, generally involves the articulations of the ossicles 
and produces lesions which greatly impair the acuteness of 
hearing. When the perforation is near the center of Shrap- 
nell's membrane the neck of the malleus is exposed, while 
perforation through the anterior portion of the drum-head, 
being directly over the tympanic extremity of the Eustachian 
tube, yields a loud perforation whistle. Rivini has described 
a perforation or foramen existing in the membrana flac- 
cida as a normal condition. Although such a " foramen " 
24 




Fig. 213. — Right memlirana 
tympani of a boy of five years, 
with constant discharge for three 
years. A perforation about 1.5 
mm. in diameter is with difficulty 
seen above the short process, and 
intratympanic injections bring 
away epithelial flakes and masses 
of fetid secretion. The rest of 
the membrane is slightly opaque, 
thickened, and injected (Ran- 
dall). 



370 DISEASES OF THE NOSE, THROAT, AND EAR 

is frequently seen just above the short process, it is be- 
Heved by most aurists to be pathologic. 

When a large perforation in the membrana vibrans in- 
volves a considerable part of the malleus handle the tip of 
this process is usually destroyed by necrosis ; should, how- 
ever, the malleus handle become attached to the promontory 
this does not occur. Large perforations may exist in the 
membrana vibrans without the hearing being greatly im- 
paired, unless the perforation be so placed as to impair the 
support that the membrana normally gives to the ossicles. 

Prognosis. — Perforations of considerable size permit free 
access of dust, cold, moisture, an'd other irritants into the 
tympanic cavity, and predispose the patient to recurring 





Fig. 215. — Inflation of the middle ear 
forces the delicate cicatrix out like a bubble 
into the meatus, where it seems larger than 
the opening- and hides its edges and the 
handle of the malleus. In a few minutes 
the distended sac loses its tension and be- 
comes plicated as it collapses, soon to re- 
sume its old position in contact with the 
inner tympanic wall (Randall). 



Fig. 214.— a large rounded loss of sub- 
stance of the membrana tympani below 
reaches up to the tip of the manubrium, 
which projects slightly into the upper mar- 
gin. It is closed by a delicate cicatrix 
applied to the promontory and molded 
upon its inequalities. The edges of the de- 
pression are sharp cut and overhang, so that 
the area seems an unclosed perforation 
(Randall). 

attacks of otitis media. Sometimes the perforation grad- 
ually becomes closed by cicatricial material. Indeed, 
nearly the whole drum-head may be replaced in this 
manner. But, although the tympanic cavity is by this 
means protected from cold or dust-laden air, the acutencss 
of hearing is generally more or less impaired if the surface 
of cicatricial tissue be large, and such cicatricial areas break 
down readily during attacks of acute catarrh of the middle 
ear. 

When seen by reflected light cicatricial areas generally 
appear somewhat depressed below the level of the rest of 
the drum-head, and they are .Sometimes so transparent that 
the structures within the tympanum are readily discernible 



DISEASES OE 77 /E Mli)7)I.E EAR 3/1 

through them (Fig. 214). If rarefaction of the air within 
the auditory canal is produced by Sieglc's pneumatic spec- 
ulum, a cicatrice will be seen to move farther outward than 
the rest of the membrane. When large and very thin and 
lax, a " ballooning " of the cicatrice results from inflating 
the middle ear by means of Politzer's air-douche (iMg. 215). 

Treatment. — When all discharge has ceased from the 
tympanum an effort should be made to close the perforation 
in order to prevent the irritating effects of dust and cold 
upon the exposed intratympanic mucous membrane. 
Closing of the perforation, when small, can be brought 
about by rubbing its edge from time to time with a few 
fibers of absorbent cotton wrapped about the end of an 
Allen probe and saturated with fuming nitric acid. The 
acid destroys the epidermal scales or cells which otherwise 
would extend from the external or dermal surface of the 
drum-head and prevent the growth of granulations. By 
keeping the edge of the opening in the drum-head *' raw " 
— that is, free from epidermis — by means of the acid, the 
granulations finally unite in the center of the perforation, 
which then becomes closed. The same thing can usually 
be accomplished by the method devised by Blake, which 
consists in placing a little disk of writing-paper over the 
perforation. A disk of sufficient size to cover the opening 
is cut from ordinary writing-paper and is soaked for a few 
moments in corrosive sublimate solution (i : 5000). It is 
then placed on the end of a cotton-tipped Allen probe and 
carried through a speculum to the drum-head over the 
perforation. It adheres somewhat firmly to the edge of the 
perforation because of the sizing or glue which all writing- 
paper contains. 

The paper disk acts as a stimulant and support to the 
granulations springing from the edge of the perforation, so 
that they finally unite in the center and the opening is closed. 
It is somewhat instructive to note from week to week the 
changing position of the disk of paper. Roughly speaking, 
the epidermal scales grow from the center of the drum- 
head toward its periphery, and thence outward along the 
canal, and hence the disk of paper which was placed over 
the perforation in the drum-head within a few weeks is 



372 DISEASES OF THE NOSE, THROAT, AND EAR 



seen to be upon the wall of the canal. If, in the meanwhile, 
the perforation in the drum-head has not closed, another 
disk of paper should be placed over it, 
and so on until the perforation has closed. ^!y^ 

When a perforation is so large that the 
support of the tympanic membrane to the 
ossicles is destroyed the chain of small 
bones tends to sag outward by its own 
weight, and the acuteness of hearing is 
considerably impaired. If the Toynbee 
^^^^ artificial membrana tym- 

pani (Fig. 216) be so 
placed as to give the 
requisite amount of sup- 
port when this condition 
exists, considerable im- 
provement of the acute- 
ness of hearing will re- 
sult ; but little disks of 
paper, linen, silk, or com- 
pressed cotton answer a 
still better purpose, and 
a thread may be passed 
through the center of such a disk to facilitate its removal 
from the auditory canal. Gruber has contrived an apparatus 
(Fig. 217) for the introduction of such artificial drum-mem- 
branes by the patient himself, who, after 
□ a little preliminary instruction, can usu- 
ally introduce one in a manner to secure 
the crreatest increase of the hearing- power 



Fig. 216. — Toynbee's 
artificial drum-head. 



Fig. 217. — Contrivance 
for introducing artificial 
drums (Gruber). 



It is astonishing how tolerant the ear 
sometimes becomes to the presence of 
such objects, which can often be used 
for a long time without any deleterious 
results. It is not a matter of indiffer- 
ence as to the material employed in 
the manufacture of the artificial drum- 
heads. Some patients hear best with 

disks made from one material, some with those made 

from another. 



Fig. 218. — Calcareous 
deposits in the drum- 
head after middle-ear in- 
flammation (Spalding). 



DISEASES OE THE MIDDLE EAR 373 

When a large cicatrix is present which bulges greatly 
after inflation — /. c, is very freely movable — the hearing can 
often be improved greatly by the application of a small 
quantity of contractile collodion (Formula 88). The collo- 
dion is best applied by means of a small camels'-hair brush 
after the inflation of the tympanum. The application of 
collodion should not be repeated at too frequent intervals 
or too much applied at one time, because pain and myrin- 
gitis may result. 

DISEASES OF THE TYMPANUM 

Otitis Media Catarrhalis Acuta. — Acute catarrhal inflam- 
mation of the middle ear is an acute inflammation of the 
mucous membrane of the tympanum, Eustachian tube, and, 
sometimes, of the mastoid cells, characterized by increased 
secretion of serum or mucus, but not of pus. Clinically, 
cases of acute catarrh of the middle ear are divided into 
two classes: One in which the attic of the tympanum and 
mastoid antrum are involved by the diseased process ; the 
other, in which the disease is confined to the Eustachian 
tube and atrium of the tympanum. 

Synonyms. — According to the character of the secretions 
the names applied are otitis media serosa acuta, otitis media 
mucosa acuta, and otitis media non-purulenta; according 
to the parts principally involved in the diseased process : 
Otitis media catarrhalis ex tubae, otitis media catarrhalis 
cum ostltide mastoidae, acute Eustachian salpingitis, etc. 

Etiology. — The disease is in almost all instances the result 
of exposure to cold. Chronic catarrhal affections of the 
upper respiratory tract render many individuals susceptible 
to recurring attacks of inflammation of the middle ear, 
while in many instances carious teeth have the same effect. 
Very often pain commences as a toothache, which pain ex- 
tends to the ear. In many cases the disease is the result 
of surf-bathing or of diving into water from a considerable 
height. 

In cases where acute catarrh results from diving and surf- 
bathing the direct impact of water upon the drum-head 
produces sufficient traumatism to cause the disease. A 
large auditory meatus, a cicatricial drum-head, or a perfo- 



374 JO)ISEASES OF THE NOSE, THROAT, AND EAR 

rated drum render the middle ear more liable to traumatism 
while bathing, and such individuals should never dive or 
bathe in the rough surf without stopping the ears with ab- 
sorbent cotton saturated with vaselin to exclude the water. 
All amphibious animals have valves which exclude water 
from the auditory canal during the time the animal is under 
water and hunting dogs taught to dive sooner or later be- 
come deaf However, it is not always the forcible entrance 
of even cold water into the auditory canal that is responsi- 
ble for an attack of acute aural catarrh. Not infrequently 
in surf-bathing a wave will strike a bather in the face at a 
time when he is swallowing or performing some other func- 
tion that opens the Eustachian tubes, and under such cir- 
cumstances the water sometimes penetrates as far as the 
tympanum, and if not speedily removed is capable of caus- 
ing acute intratympanic inflammation. An accident of this 
kind once occurred to the writer and was accompanied by a 
certain amount of vertigo and syncope, and it seems not 
improbable that some cases of drowning may be the result 
of the entrance of water into the ears during surf-bathing 
or swimming in rough water. 

Occasionally fluid used as a nose-wash penetrates the 
Eustachian tubes and occasions acute tympanic catarrh or 
even suppuration, although the wash may be as bland and 
unirritating to the nasal mucous membrane as the normal 
salt solution. Bland oils may be thrown into the Eustachian 
tube with impunity, but watery solutions frequentl}^ cause 
mischief. The use of such contrivances for cleansing- the 
nasal mucous membrane as Thudicum's douche, the Ber- 
mingham douche, etc., are by no means as safe as an atom- 
izer, and acute catarrh of the middle ear has resulted from 
simply sniffing normal salt solution into the nose and blow- 
ing the nose forcibly immediately afterward, so that some of 
the fluid reached the tympanum. Should water reach the 
tympanum during bathing or a watery nose-wash be inad- 
vertently injected into the middle ear while cleansing the 
nose, PoHtzer's or Valsalva's method of inflation immediately 
should be employed sufficiently often to free the middle ear 
from the fluid. 

The exanthematous fevers, and occasionally typhoid and 



n/sKAs/'.s o/-- yy/A' a///)/)/./-: ear 375 

tuberculosis, operations in the [)()sterior portion of the nares, 
in the postnasal space, and even upon the t(j»nsils occasion- 
ally cause acute otitis. 

PatJiolooy, — The affection in most cases be^i^ins as a catarrh 
of the pharyngeal orifices of the Eustachian tubes, accom- 
panying- similar disease of the nose and nasopharynx. If 
the pharyngeal orifice of the luistachian tubes is inspected 
by means of the rhinoscope at the beginning of an attack 
the mucous membrane of the tube-mouths will be found so 
congested and swollen as to either completely close the 
tubes or at least greatly interfere with the proper ventilation 
of the middle ear. Later on the secretions from the tubes 
are abundant, becoming more consistent in most instances 
as the disease advances, so that a bulb of thick glue-like 
mucus may project from the orifices of the Eustachian tubes 
into the pharynx. The mucous follicles are sometimes 
swollen, giving a granular appearance to the tube-lips. 

The appearance of the membrana tympani varies some- 
what at the commencement of the disease. Generally it is 
pinkish in color, as the result of the congestion of the inner 
or mucous layer, and the manubrial plexus of blood-vessels 
is congested. Often the membrana is more dull and opaque 
than it is normally. Often a line as fine as a hair, extending 
across the drum-head, indicates the upper level of the fluid 
within the tympanum (Fig. 219). If the fluid within the 
tympanum is thin and mobile, it will be seen to alter its 
position with the movements of the patient or during the 
use of the pneumatic speculum. By inflating the middle ear 
by the Politzer method the fluid can sometimes be broken 
into foam and the dim outlines of minute air-bubbles dis- 
cerned through the drum-head (Fig. 220). 

The bacteria found in the secretion varies. However, 
there is practically never a mixed infection. The staphylo- 
coccus and the pneumococcus of Friedlander probably are 
the forms most commonly present. 

The prognosis under appropriate treatment is favorable. 
Most cases completely recover. In neglected cases, how- 
ever, the disease often assumes the purulent form or re- 
lapses into the chronic condition. 

Symptoms. — Generally there is pain, increased by move- 



376 DISEASES OF THE NOSE, THROAT, AND EAR 

ments of the jaw, pressure over the tragus, or gently pulling 
the auricle outward. Hardness of hearing will be greater 
than in simple myringitis, if, indeed, myringitis ever occurs 
without the inflammation involving, to a certain extent, the 
entire mucous membrane of the middle ear. There will be 
present tinnitus and perhaps vertigo. The appearance of 
the membrane varies according to the amount of myringitis 
present. It may bulge outward at certain spots from the 
pressure of fluid within the tympanum or the entire mem- 
brane may be flattened or even bulging as the result of the 
pressure of fluid within the tympanum. The color of the 
membrane may be nearly normal in appearance. There 
may be more or less congestion about the periphery or the 




Fig. 219. — Collection of fluid exudate in 
the lower part of the tympanum, m'arked 
by a glistening line across the membrane. 
From the right ear of a young man in the 
middle of an acute coryza. Cure by Polit- 
zerization (Politzer). 




Fig. 220. — Foamy secretion in the tympa- 
num after inflation, in a case of serous 
accumulation. From a patient with acute 
nasopharyngeal catarrh (Politzer). 



region of the malleus handle. In the later stages of the 
disease, if rupture of the drum-head be delayed, the swell- 
ing of the drum-head is so great that the outline of the 
malleus handle is lost to view and the drum-head is not 
distinguishable by color from the surrounding red and 
swollen skin of the canal. 

Treatment. — In most cases of acute catarrh of the middle 
ear, if seen early, it is advisable to prescribe J gr. of cal- 
omel combined with 5 gr. of the bicarbonate of sodium, to 
be taken every hour for six hours, for the double purpose 
of securing free evacuation of the bowels and the alterative 
effects of the calomel, as it has been maintained that small, 
frequently repeated doses of calomel have the power of 
controlling inflammation of mucous membranes. 



\ 



DISEASES OF 77 /E MID DEE EAR 377 

The pain is often relieved by the use o( leeches. It is cus- 
tomary, in cases where there is severe pain, to apply at least 
three leeches, one in front of the tragus, one on the mas- 
toid as close to the auricle as possible, and one just beneath 
the auricle in the angle between the jaw and mastoid proc- 
ess. These points are selected because they are the posi- 
tions where the circulation of the middle ear is most readily 
depleted. The leeches should be the largest procurable 
and the wounds should be encouraged to bleed for a time 
after their removal. 

A half-century ago leeches were much more freely used 
in the treatment of acute aural catarrh than at present. 
Some writers of this period recommend that as many as ten 
leeches be applied to the margin of the auditory canal in 
relays ; that is, as fast as one leech filled and dropped off a 
fresh leech was applied as nearly as possible to the same 
spot. It is certainly true that in order to relieve the pain of 
acute catarrh of the middle ear or myringitis the blood-let- 
ting should be somewhat free and that little relief will follow 
the use of less than three leeches. The use of leeches in 
the hyperemic stage of acute otitis media when the pain is 
severe will not only relieve the pain but also will often cut 
short the progess of the inflammation. After the use of 
leeches hot applications should be made to the ear. This 
can be done by filling the auditory canal with hot water and 
afterward applying a hot flaxseed poultice over the auricle, 
but in most cases pain is more quickly and completely re- 
lieved by the instillation of anodynes into the ear and the 
application of djy heat. 

The patient may lie with the affected ear upon a hot-water 
bag or a bag of hot salt, and i or more drops of a 4 per 
cent, solution of cocain be placed within the auditory canal 
from time to time. In some cases, however, a combination 
of morphin and atropin (Formula 31) seems to act better 
as an anodyne than cocain. A hypodermic tablet of atropin 
and morphin maybe dissolved in a few drops of warm water 
and dropped into the ear. It is best to use a certain amount 
of caution in the use of powerful narcotic poisons within 
the auditory canal, as cases of poisoning have been reported. 
It is a safe rule never to drop into the auditory canal a larger 



3/8 DISEASES OF THE NOSE, THRO AT, AND EAR 

amount of atropin or morphin than can safely be adminis- 
tered by the stomach. 

It should be borne in mind in using anodynes within the 
ear that when the mucous membrane of the middle ear is 
exposed watery solutions are more readily absorbed than 
oily solutions or ointments, but that the contrary is the case 
when the drum-head is intact and absorption must take place 
through the surface of the skin ; also that inflamed surfaces, 
whether of skin or mucous membrane, absorb anodynes 
much more slowly than when no inflammation is present. 
A 3 per cent, solution of cocain painted upon the exposed 
mucous membrane of the middle ear quickly reHeves the 
pain of tympanic neuralgia, and more slowly that of active 
inflammation, but w^here the drum-head is intact a lo per 
cent, ointment of cocain and lanohn will give greater relief 
from pain than a watery solution. However, in either the 
relief from pain is somewhat tardy if considerable inflam- 
mation be present. 

When fluid is present within the tympanum an attempt 
should be made to evacuate it by the use of the Politzcr air- 
douche. The nose and nasopharynx should first be cleansed 
by the spray from an atomizer containing an alkaline solu- 
tion (Formulas i to lo) and a piece of absorbent cotton, 
saturated with a 4 per cent, solution of cocain, inserted with- 
in each nasal chamber. After contraction of the turbinated 
bodies has been secured, the nasal chambers and the vault 
of the pharynx should be sprayed with a 4 per cent, solu- 
tion of antipyrin to maintain the effects of the cocain for 
several hours and relieve congestion of the pharyngeal lips 
of the Eustachian tubes. The Politzer air-bag should now 
be filled with the vapor of menthol-chloroform and used 
with no more force than is necessary to free the tube and 
middle ear from mucus. This treatment should be repeated 
once or twice a day, omitting the use of the cocain and anti- 
pyrin if the nasopharyngeal mucous membrane be not suffi- 
ciently swollen to require it. 

If, notwithstanding antiphlogistic and other measures, 
there is bulging of the tympanic membrane, with indications 
that a perforation is likely to occur, it should be punctured 
by a paracentesis needle at the most prominent point of bulg- 



DISEASES OE 7 HE MIDDLE EAR 379 

ing or in the posterior inferior quadrant. This operation is 
harmless if antiseptic precautions be observed. The canal 
should be cleansed by wiping it out with a pledget of cotton 
wrapped about an Allen probe saturated with peroxid of 
hydrogen. It should then be syringed gently with warm 
corrosive sublimate solution (i : 2000). After being steril- 
ized a knife (Fig. 229, c or/) should be thrust through the 
membrane. If the malleus handle is not invisible as the 
result of swelling, the operator should make the puncture 
on a level with the tip of the malleus handle and midway 
between it and the periphary of the drum-head, and cut 
downward as far as possible while the knife is being with- 
drawn. If this technic is observed it will tend to avoid 
puncturing the bulb of the jugular vein, which in some cases 
lies immediately beneath the mucous membrane of the 
floor of the tympanum, without an intervening lamina of 
bone. Should the vein accidentally be punctured the 
hemorrhage for a moment may be quite free, but is readily 
controlled by packing the canal with iodoform gauze. 

Puncturing a normal drum-head after the parts have been 
cocainized is not a very painful procedure, but when inflamed, 
paracentesis causes severe pain even after the fundus of the 
canal has been soaked in a 4 per cent, solution of cocain for 
ten or fifteen minutes. Therefore, if the operation is per- 
formed without a general anesthetic, it should be done with 
the utmost quickness. The thrusting of the knife through 
the drum-head is sometimes followed by the escape of air 
with an audible hiss. At other times there is an escape of 
fluid which quickly fills the entire canal, but in some cases 
there is little fluid secreted for some hours after the opera- 
tion. The canal in either case should be stopped with a 
loose plug of sterile iodoform gauze, which should be 
changed as often as it becomes saturated by secretions. 

The relief from pain occurs in some cases within a few 
moments after the operation. In other cases an hour or 
more elapses before the pain begins to subside. There are 
but few if any cases where no relief from pain is afforded by 
the operation. 

Otitis Media Catarrhalis Subacuta. — The name is some- 
times applied to that stage of catarrhal disease intermediate 



380 DISEASES OE THE NOSE, THROAT, AND EAR 

between the acute and chronic forms. However, by stib- 
acute catarrh of the middle ear or simple acute otitis media 
is generally meant an inflammation less severe in type than 
the acute. Pain is neither severe nor long continued and 
the patient is deaf only for a short time. The attacks occur 
at frequent intervals. Upon examination the membrana 
tympani is found pinkish in color and is decidedly opaque 
and lacks its usual lustre. The cone of light is either smaller 
than normal or has entirely disappeared. As the drum- 
head never ruptures, permitting an examination of exudates, 
the kind of bacteria present is a matter of conjecture. It is 
doubtful if any be present, as, according to Hassleur and 
Preysing, no bacteria are present in the normal middle ear. 

Etiology. — The disease is commonest in children as the 
result of disease of the nose and pharynx, hypertrophied 
pharyngeal tonsil being an exceedingly common cause of 
the affection, Bad nutrition, carious teeth, and frequent 
attacks of coryza are common predisposing causes. 

The treatment should be directed toward improving the 
patient's general health and removing any predisposing cause 
of the affection. If the teeth are carious they should receive 
the attention of a skilful dentist, while the efforts of the aurist 
should be carefully directed toward the removal of any 
morbid condition existing in the nose and nasopharynx, 
because experience has amply demonstrated that in most 
cases attacks of subacute aural catarrh cease to recur as 
soon as a cure is brought about of the concomitant naso- 
pharyngeal disease. The knowledge of this fact, however, 
is not an excuse for neglecting local treatment of the ears 
while the nose and nasopharynx are receiving attention. 

Adenoid growths and hypertrophied faucial tonsils should 
be reduced in size, the former by means of Gottstein's curet 
and the latter by the tonsillotome or by ignipuncture in the 
manner already described. 

At each biweekly or triweekly visit of the patient the nose 
and nasopharynx should be cleansed by means of an atom- 
izer filled with an alkaline antiseptic wash (Formula i or 2), 
after which the ears should be carefully inflated by means 
of Politzer's air-bag. If the inflammation of the middle ear 
is not too active, *' massage " should be applied to the drum- 



\ 



DISEASES OF THE iM I J) J) J.I': EAR 38 1 

head and the ossicles by the aid of Siei^le's pneumatic specu- 
lum, after which there should be made to the interior of the 
nose and nasopharynx an application of an iodin solution 
(Formula 33) in the case of children, or an astringent solu- 
tion (Formulas 34, 35) in the case of adults, and the parts 
covered with albolene by means of the spray from an atom- 
izer. 

The hygienic surroundings of the patient should receive 
careful attention and tonics and cod-liver oil prescribed in 
suitable cases. In children catarrhal inflammation is gener- 
ally of an adenoid character ; that is, the lymphatic elements 
of the mucous membrane bear the brunt of the disease, so 
that children and young adults do well upon iodin compounds 
applied locally and given internally. Syrup of the iodid of 
iron should be prescribed for internal use, with or without 
cod-hver oil, as the circumstances of the case require, while 
hypertrophy of the lymphatic glands underneath the skin of 
the neck should be treated by inunctions at bedtime of a 
10 per cent, ointment of ichthyol in lanolin. The ointment 
should be rubbed lightly into the skin and the bedclothing 
protected by waxed paper and a bandage about the child's 
neck. 

Catarrh in adults is often characterized by inflammation 
o( the mucous glands and interstitial elements of the mucous 
membrane ; and it is in such cases that sedative applications 
and astringents are most useful. The vapors of various 
volatile substances are sometimes applied to the middle ear 
by means of Politzer's air-bag. The most useful of these 
substances are iodin, menthol, and chloroform. Glass- 
stoppered bottles, each partly filled with one of these 
drugs (Formulas 90-93), should be at hand in the office, 
so that the Politzer air-bag can readily be filled with the 
vapor of the drug which it is desired to use by inserting the 
nose-piece of the instrument within the neck of the bottle. 
The vapor can then be made to reach the mucous mem- 
brane of the middle ear by Politzer's method or by the 
employment of a Eustachian catheter. The vapor of iodin, 
when thrown into the middle ear, acts as an alterative and 
gentle stimulant, that of menthol as a sedative, while chloro- 
form vapor is probably simply a stimulant. It is generally 



382 DISEASES OE THE NOSE, THROAT, AND EAR 



easier to inflate the middle ear when the air-bag is filled 
with chloroform vapor than when it contains simply air. 

Otitis Media Catarrhalis Chronica. — Chronic catarrh of the 
middle ear is a chronic non-suppurative inflammation of the 
mucous membrane and submucous tissues of the middle 
ear, producing deafness, tinnitus, and sometimes vertigo and 
other symptoms of altered auditory functions. 

There are two varieties of the disease — the hyperplastic and 
the atrophic — which are simply stages of the same disease. 

Synonyms. — According to its stage, the disease is some- 
times known as moist and dry catarrh, hypertrophic and 
atrophic, catarrhal, and proliferous inflammation of the 
middle ear. 

Pathology. — Gradual progressive changes take place in the 
mucous membrane and submucous tissues of the middle ear, 
similar in character to those that occur in the mucous mem- 
branes of other parts of the body, and analogous to cirrhosis 
of the liver, kidneys, or lungs and sclerosis of the brain and 
spinal cord. There is first hyperemia and hypertrophy, then 
hyperplasia and, finally, sclerosis. 

The first stage of the disease is a dilatation and engorge- 
ment of the capillaries, with an exudation of serum and round 
cells, both from the surface of the mucous membrane and also 
into its substance. The capillaries are engorged, the mucous 
membrane is swollen and edematous ; an exudate is con- 
stantly moistening its surface. The inflammatory exudate 
within the substance of the mucous membrane contains 
rounds cells, w^hich proliferate and increase in size by a proc- 
ess of elongation, so that they are finally converted into 
newly formed connective tissue, sometimes causing cords, 
bands, and membranes similar in appearance to cicatricial 
tissue following suppuration. 

During the earlier stages of the disease the thickened 
mucous membrane is redder and rougher than normal, soft, 
and easily depressed with the end of a probe. As a result, 
however, of the gradual increase of connective tissue and 
the absorption of the more fluid parts of the exudate, the 
mucous rnembrane, while still much thicker than normal, 
is pale and quite smooth. This condition represents a stage 
intermediate between hypertrophy and atrophy of the tym- 



DISEASES OE THE MIDDLE EAR 383 

panic mucous nicnibranc. It is h)'pcr[)lasia of the mucous 
membrane. 

As a mechanical result of the contraction of the newly 
formed connective tissue the L^landular elements of the 
mucous membrane disap{)ear and it finally resembles scar- 
tissue. The mucous membrane becomes smooth, thin, and 
secretes but little fluid. In some cases atrophy or sclerosis 
of the mucous membrane of the tympanum rapidly occurs 
without any pre-existing stages of hypertophy. Such cases 
are often the result of syphilis or they follow purulent inflam- 
mation of the mucous membrane with or without perfora- 
tion of the drum-head. 

It should not be supposed that the changes in structure 
above described progress evenly throughout the entire 
mucous membrane. Often depressed, scar-like spots of 
atrophy are seen in the midst of the rough, succulent, and 
swollen mucous membrane characteristic of the hypertrophic 
stage of chronic aural catarrh. 

Not only are the mucous and submucous structures 
involved in long-continued catarrh of the middle ear, but 
the bony structures are affected as well 
and, ultimately, the labyrinth also. The 
cavity of the tympanum becomes more 
roomy, and as a result of interference with 
the nutrition o{ the parts chalk deposits 
take place in the deeper layers of the mu- 
cous membrane close to the bone, in the 
membrana tympani, the membrane of the 
round and oval windows, and in the li"-a- ^'g- 221.— schematic 

, ., I'll section of a case of at- 

ments and cartilages connected with the tachment of the manu- 
ossicles. The ossicles frequently become ["JryTp'-iit'-eo/"^'''"''" 
ankylosed, and adhesions form which bind 
them to one another or to the surrounding bony walls of 
the tympanum, while bands of newly formed connective 
tissue may extend across the tympanum or mastoid an- 
trum. The membrana tympani and manubrium sometimes 
become adherent to the promontory (Fig. 221). 

Ordinarily, catarrh of the middle ear is but part of a 
diseased process involving the nose, throat. Eustachian 
tubes, and mastoid cells. The stage of the disease and the 




384 DISEASES OF THE NOSE, THROAT, AND EAR 

degree of inflammation may vary in the different parts 
affected. In most instances the Eustachian tube is the first 
part of the middle ear affected. In some instances the disease 
progresses by continuity of structure from the pharyngeal 
mouths of the Eustachian tube into the tympanum ; while 
in others stenosis of the tube, from swelling of the lining 
mucous membrane or accumulation of secretions, interferes 
with the proper ventilation of the tympanum, thus produc- 
ing a partial vacuum within the cavity, a constant dry cup- 
ping, as it were, of the tympanic mucous membrane, with 
consequent engorgement of its capillaries. 

Etiology. — It is generally the result of an extension of a 
similar disease of the nasopharynx through the Eustachian 
tubes. The chronic condition may become established after 
repeated attacks of acute catarrhal inflammation of the mid- 
dle ear. Carious teeth cause chronic catarrh of the middle 
ear as the result of reflex irritation. Syphilis sometimes 
causes chronic catarrh of the middle ear, but more often 
suppuration occurs as the result of diphtheria, measles, 
scarlatina, or typhoid fever. Those constantly exposed to 
loud noises as the result of working at certain trades, like 
boiler-making, are especially prone to lose their hearing. 
Syphilis, scrofula, and any condition of lowered vitality, 
inherited or acquired, may be enumerated as predisposing 
causes of the disease. 

Subjective Symptoms. — There is gradually increasing deaf- 
ness. The decrease in the power of hearing is, however, by 
no means uniform. Successive attacks of subacute exacerba- 
tions of the catarrhal inflammation produce comparatively 
great impairment of the hearing power, which in turn some- 
what improves. In this manner the disease progresses, the 
hearing being better or worse from week to week, but be- 
coming gradually less impaired from year to year. Many 
patients hear better during clear, dry weather than on rainy 
or damp days. This is not the result of any change in the 
acuteness of hearing, but due simply to the fact that dry, cold 
air is a better conductor of sound than moist air. The 
acuteness of hearing may not decrease to the same degree 
for all sounds. Many patients hear a watch tick at almost 
the normal distance, but hear spoken words very indistinctly. 



i 



DISEASES OE THE MIDDLE EAR 385 

In Other cases the impairment of hearing is most manifest 
for musical tones, Hke those emitted by a tuning-fork. i\ 
common remark from some patients is that* they hear the 
sound of the voice distinctly, but are unable to distinguish 
the words spoken. This slow hearing is probabl}' due to 
the sluggish action of the tensor tympani and stapedius 
muscles, whose action changes the tension of the ossicular 
chain, so that under normal conditions it is instantly tuned 
to the pitch of each sound. Hence most deaf persons hear 
words best not when spoken in a loud voice, but when 
spoken slowly and distinctly. 

A sense of fulness and discomfort within the ear and cer- 
tain modifications of the hearing are not uncommon during 
the course of chronic aural catarrh, the commonest modi- 
fication of the hearing power X^o^iw^ paracusis Willisii or in- 
creased hearing power in the midst of noise, as, for example, 
when the patient is on a moving railroad train. This 
phenomenon has been ascribed to great rigidity of the 
ossicles and contraction of the tensor tympani muscle, 
and it is of sinister import as to the ultimate effects of 
treatment. 

Dysacousvia or dysesthesia acoustica is a condition in 
which loud noises or even those of moderate intensity cause 
painful sensations. When the patient hears his own voice, 
somewhat altered in character and pitch, as if it came from 
a distance or through the tissues of his head, the symptom 
is called autoplioiiy. Paracusis duplicata and paracusis 
diplocusis are names given to the phenomenon in which the 
patient hears sounds as if repeated twice, the second sound 
seeming somewhat like an echo of the first. Probably in 
most cases of chronic catarrhal deafness sounds are not only 
altered in intensity but also in pitch and character as well. 
It is difficult, however, to observe any subjective alteration 
in the character or pitch of musical notes, except in the 
case of musicians who are deaf only in one ear. In such 
cases not infrequently the note of a tuning-fork will seem to 
be of a different character and pitch when sounded before 
the deaf ear from that emitted by the same fork when 
sounded before the patient's normal ear. When subjective 
alteration of the character and pitch of sounds is sufficiently 

25 



386 DISEASES OF THE NOSE, THROAT, AND EAR 

manifest to be a source of discomfort to the patient the 
name psciLdacousnia, or false hearing, is appHed. 

Tinnitus, subjective ringing or hissing sounds heard in the 
ear, is a symptom of aural catarrh rivalHng in importance 
even progressive hardness of hearing. It is sometimes the 
only symptom of which the patient complains, the fact being 
that, although he is somewhat deaf, yet his hearing is still 
sufficiently acute for the ordinary purposes of his life and 
occasions no discomfort. Some such patients are actually 
surprised when tests of their hearing demonstrate that it is 
defective. This is especially the case when only one ear is 
diseased. Tinnitus is usually worse at night and it may not 
be present at all in some cases during the daytime. It is 
subject to great variations in degree in some cases of aural 
catarrh, disappearing for months at a time and then reap- 
pearing. Usually tinnitus disappears in the later stages of 
the disease. Involvement of the labyrinth may increase or 
decrease tinnitus, according as the nerve-fibers are simply 
irritated or destroyed. 

Vertigo is a symptom of chronic otitis media, usually 
transitory in character. In all cases it is probable that aural 
vertigo is due to some condition within the semicircular 
canals of the labyrinth : generally it is an alteration of the 
normal interlabyrinthine pressure produced by increased 
tension exerted through the fenestrae or by a contracted 
tensor tympani through a rigid chain of ankylosed ossicles. 
Only when striLctural changes have occurred to the tissues 
within the labyrinth should the name " Meniere's disease " 
be given to a condition which otherwise is simply aural ver- 
tigo and one of the symptoms of disease of the middle ear. 

The most important objective symptoms are those revealed 
by inspection of the membrana tympani, ascertaining the 
condition of the Eustachian tubes, and testing the hearing 
by means of the voice, the watch, and tuning-forks. 

Although the condition of the membrane is not invari- 
ably an index of the condition of the tympanum, yet certain 
inferences may be drawn from its appearance that are the 
more valuable because it is the only visible part of the tym- 
panum. The lustre and color of the drum-head may be 
nearly normal both at the commencement of chronic otitis 



DISEASES OE 77/ E MIDDLE EAR 387 

media and also at a stage of the disease when the atrophic 
changes are not far advanced. In the latter condition, how- 
ever, the membrane is generally abnormally translucent, so 
that a red reflex from the promontory is discernible, and 
also the outlines of the descending process of the incus 
and the incudostapedial articulation. During the hypertro- 
phic period of catarrh of the middle ear evidences of in- 
volvement of the drum-head are usually not lacking. There 
may be patches of opacity or the whole drum-head may 
have lost its translucency and appear white, rough, thick, 
and opaque. The light spot may not occupy its normal 
position as the result of an indrawing of the drum-head or 
it may be smaller than normal because of a roughening of 
its surface, and from the same cause or from local depres- 
sions it may divide into two or more macular. If the drum- 
head is greatly depressed a light spot sometimes appears 
over the short process, which projects outward through the 
tightly drawn tissues like the knuckle of a finger. The 
handle of the malleus is, under such circumstances, fore- 
shortened, appears shorter than normal, or it maybe drawn 
so far backward as to lie almost horizontal beneath the pos- 
terior fold. Spaces abnormally white and opaque may be 
interspersed upon the same membrane with spots abnor- 
mally thin and translucent. 

It is always a matter of considerable importance to deter- 
mine the resiliency and tension of the membrane. This 
may be effected by observing the movements of the drum 
through Siegle's pneumatic speculum (Fig. 31) during rare- 
faction and compression of the air within the auditory canal. 
When the air within the canal is rarefied by means of this 
instrument a drum-head so far indrawn that it rests upon 
the promontory may be sucked outward until it appears 
like a balloon, a groove upon its convex surface indicating 
the position of the malleus handle. Sometimes isolated 
areas upon the drum-head will exhibit abnormal mobility. 
Ordinarily such spots are cicatrices formed by the closure 
of a perforation. This appearance may be produced, how- 
ever, by localized atrophy. 

Deep localized depressions are found at spots where ad- 
hesions have occurred between the membrane and promon- 



388 DISEASES OF THE NOSE, THROAT, AND EAR 

tory (Fig. 222), such spots appearing much darker than the 
surrounding area. Sharply defined deposits of chalk, more 
especially in the posterior half of the drum-head, are not 
uncommonly seen (Fig. 218). 

The patency of the Eustachian tube is tested by the Polit- 
zer method of inflation. During the earlier stages of the 
disease the tubes are usually somewhat obstructed, but 
during the later stage they are abnormally patulous. A 
favorable prognosis may be given the patient if after infla- 
tion of the tympanum the hearing is greatly improved. 
Under such circumstances the impairment of hearing is 
largely due to obstruction of the Eustachian tubes — a con- 
dition amenable to treatment. If, however, the tympanum 
is easily inflated by the Politzer method and there results 




Fig. 222. — Residua of middle-ear suppuration. Transverse section (schematic), show- 
ing-adhesions of drum-head to promontory. Front view, showing old cicatricial center 
lesions (Spalding). 



considerable outward movement of the membrana tym- 
pani without much improvement in the hearing, the pros- 
pect of speedily improving the acuteness of hearing without 
operative interference is not encouraging. 

In the hyperemic and hypertrophic stages oi catarrhal 
deafness hearing for the voice is usually proportionately 
better than for the watch and tuning-fork ; in the atrophic 
form of the disease, however, the reverse is usually the case. 
If only one ear be affected, a vibrating tuning-fork placed 
on the vertex, forehead, or teeth (Weber's method) is heard 
best in the affected ear so long as the functions of the audi- 
tory nerve and labyrinth are unimpaired. When, however, 
serious involvement of the labyrinth has occurred, tissue- 
conduction, as tested by Weber's method, will be found 



DISEASES OF THE MIDDLE EAk 389 

greatly diminished or even abrogated upon the affected side. 
Before involvement of the receptive apparatus has occurred 
a vibrating tuning-fork with its handle upon the mastoid 
will be heard better than when its vibrating tines are held 
in front of the ear (Rinne negative). Rinne's test is posi- 
tive when the labyrinth is seriously involved, and under such 
circumstances hearing both by tissue and aerial conduction is 
more greatly impaired for the higher notes of the musical 
scale than for the lower notes. 

The prognosis is only favorable in cases in which the dis- 
ease has not progressed beyond the early hypertrophic 
stage of the disease. Fluid exudates will be absorbed as 
the result of treatment and simple inflammation of the 
mucous membrane of the tympanum will disappear. The 
prognosis is all the more favorable if the disease is the 
result of pathologic conditions within the nose or naso- 
pharynx, because in such cases, when the nose and throat 
are restored to a nearly normal condition, chronic aural 
catarrh of recent origin usually subsides as the result of 
appropriate local treatment. The progress of the disease 
can, in most instances, be delayed, but when new connectiv^e 
tissue has formed it remains and atrophied parts cannot be 
regenerated. The prognosis is generally hopeless, so far as 
improvement of the hearing is concerned, in cases in which 
the labyrinth is seriously involved. However, this may be 
said for the comfort of those to whom an unfavorable prog- 
nosis is given : Chronic middle-ear catarrh is, to a con- 
siderable extent, a self-limited disease that progresses irreg- 
ularly and with greater or less rapidity to a certain degree 
of deafness, after which the progress is slow. None be- 
come completely deaf. 

Treatment. — An effort should be made to improve the 
hygienic surroundings of the patient and to so improve his 
general health as to render him less liable to contract colds. 
The nose and throat, if necessary, should receive appropriate 
treatment. Hypertrophies, ecchondroses, and exostoses of 
the nasal chambers and adenoid vegetations in the pharyn- 
geal vault should be removed ; hypertrophied faucial tonsils 
should be reduced to their normal dimensions. While 
the immediate effect of any measure to secure free nasal 



390 DISEASES OF THE NOSE, THROAT, AND EAR 

respiration may not be apparent in improved hearing, the 
freedom from frequent stenosis of the nares from colds and 
consequent irritation of the middle ear will, after a month 
or two, scarcely fail to attract the patient's attention. 

Triweekly or even daily inflation of the Eustachian tubes 
is of great importance. For this purpose Politzer's method, 
when possible, should be employed in hypertrophic cases. 
In atrophic cases, however, the irritation produced by the 
introduction of the Eustachian catheter is sometimes of 
marked benefit. Either simple air or air saturated with the 
vapor of chloroform, iodin, menthol, or turpentine may be 
used for producing the inflation (Formulas 90-93). 

In cases where the labyrinth is involved Politzer's method 
of inflation should be used with extreme gentleness if at all. 
Ordinarily in atrophic cases the Eustachian tubes are widely 
dilated, and the violent use of Politzer's bag causes a most 
unpleasant sensation to the patient and an immediate de- 
crease in the hearing power, which gradually grows worse 
from repetition of the treatment. 

Many cases of atrophy not too far advanced are greatly 
benefited by a spray of menthol and camphor in fluid albo- 
lene (Formula 17), thrown into the middle ear by means 
of the Eustachian catheter and atomizer. After introduc- 
ing the catheter and applying the auscultation-tube the patu- 
lency of the Eustachian tube is tested by means of Politzer's 
bag (Fig. 187). The nozzle of an atomizer then is inserted 
within the proximal extremity of the catheter. In cases 
where the Eustachian tube is widely dilated the spray from 
the atomizer will be heard to enter the tympanum ; but in 
most instances it enters the Eustachian tube for but a short 
distance except during the act of swallowing by the patient. 
After a time a certain amount of oil condenses in the catheter 
and Eustachian tube. This should be blown as far up the 
tube as possible by means of Politzer's bag. 

It is convenient to use an air receiver to work the atom- 
izer in order to secure steadiness of its tip when inserted into 
the catheter, but with a little care an ordinary hand atom- 
izer may be employed without inconvenience to the patient. 
It is doubtful if a large amount of the oil actually enters the 
tympanum in the majority of instances, and an excessive 



DISEASES OF THE MIDDLE EAR 39 1 

quantity if present would be removed when Politzerization 
is employed after the use of the atomizer, and hence the 
method is entirely free from danger. When the Eustachian 
tube is contracted the oil seems in some instances to act 
like a Eustachian bougie and secures dilatation. 

Stricture of the Eustachian tube may be dilated by care- 
fully passing a Eustachian bougie through the stricture, but 
the use of this instrument requires the utmiost care to avoid 
a disastrous or even fatal result from emphysema as the 
result of tearing the tubal mucous membrane. 

The diagnosis of stricture of the tube is made by means of 
the catheter and auscultation-tube. Air is not heard to 
enter the tympanum. This may be due to simple swelling 
of the mucous membrane, transient in character, which can 
be made to yield by blowing a drop or two of a 4 per cent, 
cocain solution from the catheter into the tube, followed 
in a few moments by an oily spray of adrenalin (i : 1000) 
through the catheter. If after a few moments air is heard 
to enter the middle ear through the catheter, the Eustachian 
tube may be sprayed with menthol-camphor-albolene in 
the manner previously described. 

If, however, these measures fail to secure the entrance of 
air into the middle ear, employment of the Eustachian bougie 
is a justifiable procedure. As long as no stricture is encoun- 
tered the bougie can be passed somewhat readily from the 
catheter along the Eustachian tube. If resistance is felt it 
may be due to the normal narrowing of the tube at the 
isthmus. The bougie should be marked in millimeters in 
such a manner that it is possible, by referring to these 
markings, to know the exact position of the distal end of the 
bougie and when it has entered the isthmus or junction of 
the cartilaginous and bony portions of the tube. It is not 
desirable to push the bougie much beyond this portion of 
the tube. 

If a stricture is encountered a resistance will be felt to 
the onward passage of the bougie, which usually can be 
overcome by gentle pressure for a few moments. After the 
bougie has passed beyond the stricture it should be allowed 
to remain in position for a few minutes and then withdrawn. 
When it is impossible to pass a bougie of hard rubber or 



392 DISEASES OF THE NOSE, THROAT, AND EAR 

whalebone, an attempt may be made to destroy the stricture 
by electrolysis. Duel has devised gold bougies of three 
sizes for this purpose, one of which is passed through a 
rubber-covered catheter into the tube until the stricture is 
encountered. The sponge from the positive pole of the 
battery is applied to the patient's neck and the negative pole 
is connected with the bougie. The current is then gently 
turned on to a strength not exceeding 3 to 5 milliamperes. 
The bougie is held firmly in contact with the stricture and 
after a moment is felt to pass through it. 

The treatment causes no pain and may be repeated at 
intervals of once a week. It is safer not to attempt to 
inflate the middle ear immediately after the passage of a 
bougie. The patient, however, may return the next day to 
have his ears inflated. 

The bougie may be passed into the Eustachian tube after 
the passage has been oiled with the spray from an atom- 
izer containing albolene or a few drops of a 50 per cent, 
solution of argyrol may be dropped into the catheter before 
passing a hard-rubber bougie through it into the tube. 

Massage of the Middle Ear. — Next in importance to infla- 
tion of the middle ear is systematic massage by means of 
Siegle's pneumatic speculum or some other massage instru- 
ment (Figs. 31-33), by means of which the air within the 
auditory canal can alternately be rapidly condensed and 
rarefied, and motion be thus imparted to the membrana 
tympani and ossicles. This procedure is almost invariably 
followed by an ameHoration of tinnitus if this symptom be 
present, and it probably constitutes the most satisfactory 
treatment for this annoying symptom, although freezing the 
tissues over the mastoid process by means of the spray 
from a tube of ethyl chlorid and exhausting the air within 
the auditory canal by a plug of oiled absorbent cotton 
sometimes yield good results. 

Systematic massage of the middle ear by means of the 
patient's finger-tips is of the greatest value, for while it is 
somewhat dangerous to instruct an individual to inflate his 
middle ears by Valsalva's method, as its frequent use is 
liable to be followed by atrophy of the drum-head and 
increased deafness, automassage with the finger-tips is 



DISEASES OE THE MIDDLE EAR 393 

entirely harmless and may be used for the relief of tinnitus 
whenever it becomes annoying. The forefinger should be 
slightly moistened and slipped into the meatus with the nail 
posterior. With rapid piston-like movements of the finger- 
tip inward and outward a patient can easily exercise alterna- 
tions of pressure and rarefaction of the air within the audi- 
tory canal, and hence massage the intratympanum almost 
as thoroughly as if a pneumatic speculum were used. He 
maybe instructed to employ the method several times a day 
with increasing relief of tinnitus in many instances and, 
generally, improvement of the acuteness of hearing. It is 
seldom that the method fails to afford at least temporary 
relief from the feeling of fulness or pressure within the ear. 

Phono mas sage, by means of sounds conveyed to the ear 
through rubber tubes from various musical instruments or 
similar contrivances, has been employed in the treatment 
of catarrhal deafness and tinnitus. If the ears of an 
individual with catarrhal deafness be subjected for a length 
of time to musical tones of about the same pitch as the 
tinnitus from which he suffers, the subjective noises will 
either entirely disappear or be greatly alleviated, probably 
as the result of fatigue of the portion of the internal ear 
adapted for the perception of sounds of that pitch. This 
method of treatment has been largely abandoned in favor 
of more rational methods. 

Pnannomassagc with, electromagnetic and other machines 
(Fig. 33) capable of producing rapid alternate rarefaction 
and condensation of the air in the auditory canal is undoubt- 
edly of benefit in a large proportion of chronic middle-ear 
catarrhs, but is probably in no way superior to massage 
with the pneumatic speculum or the tip of the forefinger. 
The same remark also applies to direct massage of the 
chain of ossicles by means of Lucca's pressure probe, 
which is a spring probe, the cup-shaped end of which fits 
over the short process of the malleus to prevent slipping ; 
and also to the so-called " internal massage," where short, 
sharp puffs of compressed air from an air-receiver are, by 
means of an ''automatic cut-off" (Fig. 42), rapidly worked 
wdth the tip of the thumb, thrown through a catheter into 
the Eustachian tube. 



394 DISEASES OF THE NOSE, THROAT, AND EAR 

The wedging of a little ball of absorbent cotton into the 
space above the short process of the malleus, where its 
weight and pressure serve constantly to push outward the 
malleus handle and the long process of the incus, thus 
diminishing pressure on the stapes, in a certain number of 
cases will afford efficient aid in the treatment of tinnitus 
and hardness of hearing. The Httle mass of cotton should 
be moistened with a suitable antiseptic solution, so that it 
can be molded to the parts when inserted above the 
malleus handle, and may with benefit in certain cases be 
worn for several weeks at a time. It is not readily dislodged 
from its position by massage either with the pneumatic 
speculum or the finger-tip, and sometimes gives immediate 
and ultimately permanent relief from tinnitus. 

Tension of the transmitting apparatus of the middle ear 
may also be decreased by operative procedures, such as 
repeated paracenteses of the drum-head, tenotomy of the 
tensor tympani and stapedius, or removal of the membrana 
tympani and one or more of the ossicles. 

The liead noises complained of by patients are almost as 
numerous as the individuals affected, but may be divided 
into three classes — the pulsating, the continuous, and sounds 
more or less elaborated, like the ringing of bells, music, and 
words and sentences uttered with more or less distinctness 
— the latter class only being referred to a point outside the 
head. 

Tinnitus is more often pulsating than patients are willing 
to admit until the fact is demonstrated to them by placing 
the hand upon their pulse and beating time to it with a 
finger. Sometimes the result of anemia or, more rarely, of 
an aneurysm, pulsating tinnitus ordinarily indicates arterial 
congestion of the middle ear or of the labyrinth. The 
differential diagnosis between the two conditions can be 
made with a limited amount of accuracy by pressure upon 
the carotids or on the vertebral arteries at the point where 
they cross the atlas, because a branch of the carotid supplies 
the tympanum and a branch of the vertebral supplies the 
labyrinth. 

The faint pulsating tinnitus due to anemia is diminished 
by the patient's lying down, and in many instances can be 



DISEASES OF THE MIDDLE EAR 395 

permanently cured by hygienic measures and suitable tonics, 
among which the well-known pil. sumbul comp. is especially 
useful. Pulsating tinnitus due to congestion, on the other 
hand, may be alleviated by the bromids, of which, for a 
reason that will appear below, dilute hydrobromic acid, in 
doses of from 15 to 60 drops three times a day, is probably 
the best. 

The earlier stage of chronic catarrh of the middle ear is 
ordinarily accompanied by tinnitus, generally constant in 
character. Later on, as deafness becomes profound, tinni- 
tus often disappears as the result of diminished sensibility 
of the internal ear. Tinnitus due to middle-ear catarrh is 
sometimes alleviated by large doses of the bromids ; but 
better results can be obtained in a limited number of cases 
by the patient taking after meals, for a few weeks, a pill 
containing \ gr. of nitrate of silver, \ gr. of extract of 
hyoscyamus, and ^ gr. of strychnin. 

Inflammation of the external auditory canal, foreign 
bodies, impacted cerumen, and polypus are capable of pro- 
ducing tinnitus and, in rare cases, vertigo, nausea, cough, 
or even epileptiform convulsions. 

Not always is tinnitus the result of diseases of the ear, 
but rather is a reflex phenomenon due to the irritation of 
some correlated region — the nose, teeth, or, more frequently, 
the digestive tract. Just as acute dyspepsia is ordinarily 
accompanied by vertigo, so the more chronic ailments of 
the digestive tract sometimes occasion a tinnitus the cause 
of which is little suspected. The manner in which disease 
of the digestive tract, teeth, or nose produces tinnitus is, as 
pointed out by Woakes, through the nervous connection, 
more or less direct, of these organs with the inferior cervical 
sympathetic ganglion, which supplies the nervi vasorum to 
the occipital artery and its branch, the internal auricular. 
Irritation of the inferior cervical sympathetic ganglion 
would cause tinnitus as the result of dilation of the 
arterioles of the cochlea, which, at first pulsating, would 
afterward become constant in character as the result of 
trophic changes resulting from increased blood supply. 
Quinin, the salicylates, and certain other drugs are capable 
of producing tinnitus, either as the result of aural hyperemia 



39^ DISEASES OE THE NOSE, THROAT, AND EAR 

or by their toxic action upon the internal ear. There is 
also reason to suppose that in lithemia the products of indi- 
gestion exert a similar action in the production of tinnitus. 
It is, therefore, in cases where dyspepsia and lithemia have 
done their share in the production of tinnitus that acids, 
including hydrobromic acid, are especially useful in con- 
trolling this annoying symptom. Proper regulation of the 
diet and regular exercise in the open air and sunlight will, 
in cases where there is neither disease of the ear, nose, nor 
teeth to account for tinnitus, generally result in a disappear- 
ance of the head noises. 

The more elaborate subjective sounds, heard as if pro- 
duced outside the body — such as the ringing of bells and 
spoken sentences — are the result of disease of the ear 
acting on an easily excited brain. Some of the cases are 
at least on the border-line of insanity, and not only hear 
voices but see visions, either religious or otherwise in charac- 
ter. Benefit sometimes results from treating the concom- 
itant aural disease. 

Otitis Media Suppurativa Acuta. — Acute purulent inflam- 
mation of the middle ear is an acute purulent inflammation 
of the mucous membrane of the tympanum, and usually also 
of that of the Eustachian tube and mastoid cells. 

Pathology. — The tympanic mucous membrane is of a 
bright red color, much swollen, and devoid of its epithelium. 
There is cellular and serous infiltratiom of its connective- 
tissue layer and much exudation of mucopus or pus from 
its surface. Perforation of the membrana tympani occurs 
in the majority of cases, the pus being then discharged 
through the perforation into the auditory meatus ; occasion- 
ally the discharge is tinged with blood. 

Etiology. — Generally the disease is the result of a cold or 
of traumatism, or it may occur as a complication during 
diphtheria, scarlatina, small-pox, measles, typhoid fever, 
syphilis, or tuberculosis. Purulent inflammation of the mid- 
dle ear is very common in children. Carious teeth and 
nasopharyngeal disease are pedisposing causes of the affec- 
tion. Suppuration presupposes bacterial infection, which 
probably takes place in most instances by way of the 
pharynx and Eustachian tube. It is a general rule that the 



DISEASES OF THE MIDDLE EAR 397 

infection at first at least is monobacterial, but that after the 
niembrana is ruptured polybacterial infection commonly 
occurs from the canal. Efforts should, of course, be directed 
to prevent if posssible this mixed infection. The micro- 
organisms most commonly found in otorrheal pus are strep- 
tococcus pyogenes, pneumococcus, staphylococcus aureus 
and albus, typhoid and tubercle bacilli. Of the monobac- 
terial infections, that of the streptococcus is most likely to 
run a severe course, possibly ending in severe mastoid 
complications. 

Syiriptoiiis. — An attack is ushered in by pain in the ear, 
shooting over the side of the head. Sometimes the pain 
originates in a diseased tooth and extends to the ear. Chilly 
sensations and fever are sometimes present, the temperature 
reaching as high as 102° or 103° F. The ear feels full and 
there are tinnitus and deafness, the pressure of confined pus 
upon the secondary membrane sometimes interfering with 
the functions of the labyrinth. When perforation takes place 
there occurs a rapid alleviation of the pain and tinnitus. 

The appearance of the drum-head is that of acute myringi- 
tis. At the end of a few hours to several days or even 
weeks from the beginning of the attack a bulging at some 
point upon the drum-head indicates the position where the 
pus will burrow its way through the membrana. When, 
however, the attic and mastoid antrum contain pus which 
cannot readily drain into the atrium because of swelling of 
the mucous membrane about the ossicles, this pus will 
sometimes burrow underneath the skin of the auditory 
canal and find an exit either at some point within the canal 
or behind the auricle. Those cases in which no perforation 
occurs run a tedious course and some permanent impair- 
ment of the hearing usually ensues. The duration of the 
disease from the occurrence of a perforation to its closure 
is very variable. In cases where the perforation occurs 
early it may remain open only for a few days. Three or 
four weeks are ordinarily required for the closure of a small 
perforation. 

If the perforation is large it will probably remain open 
long after suppuration has ceased, to finally close by cicatri- 
cial material destitute of all fibers of the membrana propria. 



398 DISEASES OF THE NOSE, THROAT, AND EAR 

and will bulge inward and outward with the varying inter- 
tympanic pressure. 

Extensive destruction of the structures of the middle ear 
sometimes occurs during acute otitis media. This is espe- 
cially apt to take place when the disease appears as a compli- 
cation of scarlatina, variola, or diphtheria. The whole of the 
drum-membrane and all of the ossicles may come away 
within a few days from the onset of the middle-ear disease 
as an enormous slough. In other cases ulceration, starting 
from the perforation, proceeds more slowly, but it accom- 
plishes equally disastrous results. Inflammation of the 
mastoid is occasionally a serious complication of acute otitis 
media, and the labyrinth sometimes participates in the 
purulent inflammation of the tympanic cavity, the ultimate 
result in such cases being intracranial compHcations, often 
fatal. 

Infants affected by acute suppuration cry constantly, 
turning their heads restlessly from side to side, placing the 
hand frequently upon the affected ear. High temperature, 
reaching 103° or 104° F,, is usually present and convulsions 
sometimes occur. The infant sleeps only when completely 
exhausted or under the influence of opiates. Upon inspec- 
tion the drum-head is often found enormously swollen, pro- 
jecting into the canal like a polypus, for which it has been 
mistaken. Sleeplessness, high temperature, and restlessness 
quickly disappear after evacuation of the pus. 

The prognosis of acute purulent inflammation of the mid- 
dle ear, when it occurs in an otherwise healthy individual, 
is usually favorable, but the severity of the attack depends 
largely on the variety of bacteria causing the infection and 
their virulence. However, the disease frequently assumes 
the chronic form, and in tuberculous individuals this is the 
usual outcome of the affection. 

Treatment. — In the early stages of the disease leeches, 
hot applications, and the other measures for the relief of pain 
already specified are useful for the relief of pain in catarrhal 
inflammation of the middle ear. Paracentesis of the mem- 
brane should be done as soon as bulging occurs. The cut 
should be 2 or 3 millimeters long and should be made 
through the point at which the bulging occurs or at the so- 



DISEASES OE THE MIDDLE EAR 399 

called point of election in the posterior quadrant of the mem- 
brana tympani, midway between the malleus handle and the 
periphery (see p. 379). When there is considerable swell- 
ing of the upper posterior part of the auditory canal, indicat- 
ing the presence of pus beneath the skin of this region, the 
thrust should be through Shrapnell's membrane, and the 
knife be so withdrawn that its point will cut through the 
swollen tissues at the upper posterior portion of the canal to 
the bone, in order to secure free drainage. 

After incision of the drum-membrane or when rupture 
has occurred spontaneously the major part of the pus within 
the auditory canal should daily be removed by means of 
absorbent cotton wrapped about the end of a probe, and the 
pus within the tympanum expelled through the opening in 
the drum-head by the Politzer method of inflation. After 




Fig. 223. — Blake's polypus snare. 

this has been accomplished the auditory canal should be 
cleansed thoroughly by means of a cotton-tipped probe wet 
with a 15-volume solution of peroxid of hydrogen, the parts 
thoroughly dried, and covered wath powdered boric acid 
by means of the powder-blow'er. 

If exuberant granulations sufficiently large to obstruct free 
drainage from the tympanum occur, they should be removed 
by means of a snare (Fig. 223), by Hartmann's forceps 
(Fig. 205), or by touching them with cJiromic acid fused on 
the end of a probe. Considerable caution is required in the 
use of chromic acid. The granulations or small polypi 
should first be dried thoroughly by means of absorbent cotton, 
in order to prevent the acid dissolving and flowing over 
adjacent structures. No more of the acid should be applied 
than is necessary to accomplish the desired result, and any 
excess remaining \vithin the canal should be neutralized by 



4O0 DISEASES OF THE NOSE, THROAT, AND EAR 

syringing with a warm alkaline solution. Small polypi and 
exuberant granulations are most apt to occur and obstruct 
drainage when the pus has found its way through an open- 
ing in Shrapnell's membrane at a point on the upper and 
posterior part of the auditory canal. 

Otitis Media Suppurativa Chronica. — Etiology, — Chronic 
purulent inflammation of the middle ear is generally caused 
by neglect or improper treatment of acute purulent disease 
of the middle ear and the failure to secure adequate drain- 
age. Adenoids, nasopharyngeal disease, and malnutrition 
prevent sometimes a prompt secession of an otorrhea. The 
affection may, however, develop primarily as the result of 
syphilis or tuberculosis. Numerous cases are the result of 
scarlatina. 

Symptoms. — There is a mucopurulent or purulent dis- 
charge, sometimes tinged with blood. The acuteness of 
hearing varies according to the amount 

□ of destruction of the structures of the 
middle ear or to the presence of polypi 
or semi-inspissated secretions blocking 
the canal or interfering with the func- 
tions of the ossicles. In some instances 
the hearing is nearly normal, while 
in others deafness is nearly absolute. 
Tinnitus may or may not be present. 
Fig. 224.-Residuaofmid- jj-^g presencc of a discharo^e in 

die-ear suppuration. JN early J^ o 

total loss of the drum-head, thc auditory caual from the middle 

Handle of hammer resting , ^ 

on mucosa of promontory Car prCSUppOSCS thC preSCUCC OI a pCr- 

^^P^'^'"^^- foration of the drum-head. The per- 

foration, on the one hand, may be so minute as to escape ob- 
servation by otoscopy, its presence being only revealed by a 
"perforation whistle" during inflation of the ear either by 
Politzer's or Valsalva's method. On the other hand, the de- 
struction of the drum-head maybe so extensive as to expose 
the cavity of the typanum to view and reveal all of the 
structures of the inner wall (Fig. 224). In some cases the 
remains of the drum-head may be represented only by a 
narrow ring ; in other cases the ossicles may have also dis- 
appeared, either from ulceration and sloughing of their liga- 
ments or by necrosis of the bones themselves. Necrosis of 



DISEASES OF THE MIDDLE EAR 



401 



some portions of the tympanic walls may also exist. To a 
considerable extent the position and size of the perforation 
will indicate the position and extent of the necrotic process 
(Fig. 225). The appearance of the tympanic mucous mem- 
brane varies somewhat. In one class of cases it is simply 
red and swollen, while in another class it appears granular 
and polypi may be present, perhaps covering the orifice of 
a sinus leading to exposed bone. 

Politzer states that usually there is a destruction of the 
ciliated epithelium and a thickening of the mucous mem- 
brane from infiltration of round cells with a dilatation and 




Fig. 225. — 1-5, Simple suppurations of the drum-cavity and the Eustachian tube; 
6-8, caries of the incus ; 7, caries of the. head of the malleus ; 0, attic suppuration with 
possible caries of both malleus and incus; 10, 11, caries of the head of the malleus; 12, 
caries of the incus and suppuration of the antrum, and, possibly, associated cholesteatoma. 
(Leutert.) 

new formation of blood-vessels. That fungiform excres- 
cences cover the thickened mucous membrane, which con- 
tains small cysts lined with cylindric epitheljum and con- 
taining epithelial cells, leukocytes, and detritus. 

The bacteria of the discharges are staphylococci, strepto- 
cocci, and saprophytes. 

Prognosis. — Untreated, some cases, after discharging for 
a year or two, finally cease discharging, the perforation in 
the membrana closes, and the hearing, while not entirely 
normal, becomes fairly good. This result is most likely to 
occur in cases with perforations similar to those shown in Fig. 
225, 1-3. In other cases, where there is a large destruc- 
tion of the membrane, the discharge ceases for a time only to 
recur at intervals. In this class of cases there is only occa- 
sionally an apparent discharge, which for long intervals 
26 



402 DISEASES OF THE NOSE, THROAT, AND EAR 

never appears externally. A scanty discharge, mixed with 
dust and other materials, dries at the fundus of the canal 
until it becomes a source of irritation, when, perhaps partly 
as the result of a cold, an abundant otorrhea is set up 
which sweeps away the old inspissated accumulations. 
Gradually this abundant otorrhea subsides until for another 
period no discharge appears externally. This is not an 
infrequent termination in cases where there is a large 
destruction of the membrane, as in Figs. 224 and 225, 4. 
In cases of this character occasional careful cleansing of the 
ear and in the case of a recurrent discharge one or two 
applications at intervals of a day of a 10 per cent, solution 
of argyrol will maintain the ear in a fairly satisfactory con- 
dition. Often the hearing is fairly good. The mucous mem- 
brane of the inner wall of the tympanum rarely epiderma- 
tizes and becomes entirely dry. Occasionally, where there 
is as nearly a complete destruction of the drum-head as in 
Fig. 224, the opening will become closed by a huge thin 
cicatrice, which, ballooning inward and outward with every 
change in intratympanic pressure, is rather a hindrance than 
an aid to hearing, but serves to exclude cold, dust, and other 
irritants. 

Cases where there is a small opening in or just below 
Shrapnell's membrane leading to carious bone or an accu- 
mulation of filth (cholesteatomatous material) discharge 
indefinitely a scanty, watery fluid which sometimes dries 
upon the tympanum, forming an accurate cast of that struc- 
ture when removed. Such so-called "attic cases" (Fig. 225, 
6-12) are always a source of greater danger in the produc- 
tion of mastoid and intracranial complications than other 
forms of chronic otorrhea; although many attic cases 
reach a ripe old age, with no more serious discomfort than 
partial deafness and a scanty discharge. 

In clironic otorrhea, the result of tuberculous infection, it 
is very difficult to bring about a cure of the suppuration 
even by the most radical operations. However, such cases 
usually die from the concomitant phthisis before the tuber- 
culosis of the ear has progressed sufficiently to render a 
radical mastoid operation justifiable. 

The treatment of uncomplicated cases consists in daily 



DISEASES OF THE MIDDLE EAR 403 

thorough cleansing of the interior of the drum, already de- 
scribed as necessaiy in the treatment of acute purulent in- 
flammation of the middle ear. If the perforation through 
the membrana is not sufficiently large to permit of this being 
readily accomplished it should be enlarged or a counter- 
opening made, and the interior of the drum syringed by 
means of Blake's middle-ear cannula (Fig. 38, 2, 3, or 4). 
When, with a large perforation, pus is seen to flow down- 
ward from the attic into the tympanum, the nozzle of 
the curved cannula should be introduced into the attic 
through the perforation, so as to thoroughly cleanse this 
cavity. 

After the cavity has been thoroughly cleansed it should 
be dried carefully by means of absorbent cotton wrapped 
about a probe and the parts covered by powdered boric 
acid. The success of the treatment depends upon the thor- 
oughness with which the cleansing is accomplished at each 
daily visit of the patient. 

If the tympanic mucous membrane is .granular the routine 
treatment outlined above will not be sufficient to secure a 
speedy cessation of the discharge until the granulations are 
destroyed. Alcohol has the power to cause a shrinking of 
the granulations because of its dehydrating qualities, and 
absolute alcohol may be applied by means of a cotton-tipped 
probe at each daily visit of the patient after the ear has been 
thoroughly cleansed. The application of absolute alcohol 
causes some pain, and it may augment the discharge for a 
few days. Alcohol (95 per cent.) may also be prescribed 
for the patient's use at home, a few drops being instilled 
into the ear several times a day, care being exercised that 
the patient's head is held in such a position each time that 
the alcohol dropped into the ear will be sure to reach the 
cavity of the tympanum. For the first {^\n days it may be 
necessary to dilute the alcohol somewliat because of pain. 
However, it should be remembered that the dehydrating 
properties of. 50 per cent, alcohol are practically nothing. 
A good method of prescribing alcohol is to instruct the 
patient to mix in a 2-dram vial equal parts of alcohol 
and water for the first day's use. If this mixture causes 
only momentary pain, to use the next day 2 parts alcohol 



404 DISEASES OF THE NOSE, THROAT, AND EAR 

and I part water, and so on from day to day until 95 per 
cent, alcohol can be used without great distress. 

Before dropping alcohol into his ear the patient or one of 
his friends should be instructed to remove all accumulations 
of pus from the ear in the following manner : The auditory 
canal is first straightened by drawing the auricle upward, 
backward, and outward. A cotton-tipped wooden tooth-pick 
is then inserted gently to the bottom of the canal, allowed 
to rest there sufficiently long to absorb pus, and then with- 
drawn and discarded. This procedure is repeated until the 
cotton fails to absorb and bring away any discharge. 

In case of a child, where the parent or nurse cleanses the 
ear, the child should be placed in front of a window before 
the canal is straightened, so that the light may be directed 
into the ear and a view of the fundus of the canal obtained, 

Cleansing the ear by some method is absolutely neces- 
sary before dropping alcohol into it, as otherwise the alcohol 
will be diluted and the tissues protected by a layer of pus 
so thick in most instances that the alcohol will never reach 
the diseased parts. 

If it is deemed wise to order the patient to cleanse his 
ears with a syringe, he should be carefully instructed as to 
the proper method (p. 356), and, what is probably of as great 
importance, the proper method of drying the ear. 

Discharging ears do better under a treatment in which 
syringing has little or no part. Nevertheless it is well at 
the first treatment of a patient with chronic otorrhea to 
begin by a thorough cleansing of the canal and tympanum 
by syringing with- sublimate solution. 

The writer has very serious doubts as to the value of home 
syringing, either by the patient or his friends. A girl about 
twelve years of age was brought to the Medico-Chirurgi- 
cal Ear Dispensary some years ago almost totally deaf and 
with double facial paralysis as the result of scarlet fever. 
The odor from the child's ears was indescribably fetid. The 
mother stated that she had syringed the child's ears every 
day for the past six months. From the child's left ear there 
was quickly syringed a fetid mass of pus, the malleus, the 
incus, and part of the annulus tympanicus ; from the right 
ear, fetid pus and the malleus. In six months of daily syr- 



DISEASES OF THE MIDDLE EAR 405 

inging the parent had evidently failed to remove any of the 
accumulation at the fundus of the auditory canal, but had 
simply syringed away some of its superficial portion. The 
case illustrates the value of home syringing of the ear as 
ordinarily performed. 

For the patient's use the syringe made of a single piece 
of soft rubber (Fig. 48) is probably the safest and most 
effective instrument. All things considered, a warm satu- 
rated solution of boric acid is the most convenient deter- 
gent ear-wash for home use. The patient should be in- 
structed to place I or 2 teaspoonfuls of the crystals in a 
wide-mouthed bottle holding about 4 ounces, fill the bottle 
with warm water, syringe the ear, and afterward cork the 
bottle. At each subsequent syringing a sufficient amount 
of boiling water from the teakettle is added to bring the 
saturated solution of boric acid up to a temperature suit- 
able for syringing the ear. As the crystals of boric acid 
are dissolved more should be added from time to time in 
order to maintain a saturated solution of boric acid con- 
veniently ready for use. 

While the above furnishes a cheap and convenient method 
of cleansing the ear, the writer's feeling is that most cases 
of acute and chronic suppuration, under ordinary circum- 
stances of ready access to the aurist's office or the dispen- 
sary, do better without home syringing ; and that when 
alcohol or other drops are prescribed for home use, they 
are best dropped into the ear after a dry cleansing with 
absorbent cotton. 

Aural Polypi. — When the granulations are isolated they 
may be scraped away with a sharp curet or be removed 
with the forceps. Large granulations and polypi are best 
removed with a snare. It should be borne in mind, when 
removing a polypus with a snare, that, although the pol}-- 
pus is absolutely devoid of sensation, the wall of the audi- 
tory canal, as the result of long maceration in pus, is often 
exquisitely sensitive, and in guiding the wire loop of the 
snare over the polypus it is advisable to avoid, as far as 
possible, touching the auditory canal. If the polypus is 
large an effort should be made to locate its pedicle by means 
of a probe. The wire loop of the snare should then be 



406 DISEASES OF THE NOSE, THROAT, AND EAR 

worked gradually inward over its surface until, if possible, 
the pedicle of the polypus is encircled. The wire loop should 
then be tightened to cut through the polypus. If the ope- 
rator has not succeeded at the first attempt in removing the 




Fig. 226. — Sexton's combination forceps. 

w^hole of the polypus, this maneuver may be repeated until 
the desired result has been accompHshed. Bleeding may be 
checked at any stage of the operation by means of a tampon 
of absorbent cotton saturated with a i : 1000 solution of 




Fig. 227. — Gleason's polypus snare. 



adrenalin, and by afterward cauterizing the stump of the 
polypus with nitrate of silver fused on the end of a probe. 

For the removal of polypi Blake's snare (Fig. 223) is per- 
haps the most convenient instrument, but Sexton's, Gruber's, 
or Wild's snare is almost equally efficient. The author 



DISl'lASKS OF J'l/E MIDDI.K EAR 



407 



I 



has luid made an aural polypus snare consistin<^^of a needle 
and cannula, so constructed as to be used as an auxiliary 
" tip " with Sexton's combination forceps, so that when the 
eye of the needle is threaded with wire the loop so formed 
can be enlarged or diminished at the pleasure of the opera- 
tor — a matter of some importance in guidin<^ it along the 
auditory canal over a large polypus. Other advantages 
of this instrument are the quickness and ease with 
which it can be manipulated, and the fact that when the 
wire is in position around a small polypus the canimla can 
be thrust forward over the wire loop, and thus prevent the 
wire slipping over the polypus instead of excising it (Fig. 
227). 

Pathology. — Aural polypi (Fig. 228) may be divided into 
four classes. About 50 per cent, of all aural polypi are 
granulation tumors, having the 

same structure as ordinary granu- . "' 

lations, but covered by cither 
squamous or columnar epithe- 
lium; 90 per cent, of aural polypi, 
other than granulation tumors, 
are mucous papillomata. They 
are extremely vascular and some- 
times bleed at the slightest touch. 
Their structure consists of cap- 
illary loops surrounded by a 
stroma of somewhat imperfectly 
developed connective tissue con- 
taining cuboidal epithelial cells. 
They are covered by a pave- 
ment-epithelial layer of varying thickness. Fibroid polypi 
(fibromata), which are somewhat rare, are usually found 
as large, dense, pale polypi developed from the perios- 
teal or deeper layer of the tympanic mucous membrane. 
Fibrous polypi are also covered by several layers of pave- 
ment epithelium. Myxomatous polypi are very rarely 
found in the human ear. Aural polypi are not malignant, 
the treatment outlined above being sufficient to prevent a 
recurrence of the q-rowth. It should be borne in mind, 
however, that epitheliomata, sarcomata, and gummata some- 




FiG. 228. — Polypi (Steudener)- 



408 DISEASES OE THE NOSE, THROAT, AND EAR 

times occur in the middle ear and present the appearance 
of polypi, but such growths are rare in this situation. 

Symptoms. — Long-continued discharge, often streaked 
with blood, is usually the only subjective symptom. Cer- 
tain reflex symptoms, the result of peripheral irritation 
caused by the presence of an aural polypus, have been de- 
scribed as occurring in rare cases. 

Most aural polypi have their origin at the posterior and 
upper part of the tympanum. They may, however, arise 
from any part of the tympanic cavity or even from the der- 
mic layer of the drum-head. Sometimes they originate at 
the mouth of a sinus extending through the skin of the 
auditoiy canal to carious or necrosed bone. 

Caries and Necrosis. — Caries or necrosis of the temporal 
bone may occur during the course of long-continued sup- 
puration of the middle ear or as the result of syphilis, tuber- 
culosis, trauma, osteomyelitis, and diabetes. The upper and 
posterior part of the auditory canal, the mastoid, and the 
tegmen of the tympanum and antrum are the portions most 
usually first attacked. Caries most frequently attacks the 
cancellous, necrosis, the compact bone. 

Symptoms. — Circumscribed caries may exist within the 
tympanum during chronic purulent disease of the middle ear 
and present no symptoms other than that exposed and 
roughened bone can be detected by means of a probe. 
Sudden paralysis of the facial nerve may occur as the result 
of necrosis of the inner wall of the tympanum involving 
the facial canal ; how^ever, a considerable portion of the 
facial canal may be opened and the nerve be bathed in pus 
for some time before symptoms of Bell's palsy occur. The 
labyrinth may be opened, generally through the horizontal 
semicircular canal, and brain-abscess occur. The tegmen 
tympani and tegmen mastoideum not infrequently are de- 
stroyed as the result of necrosis or caries. Under such 
circumstances there commonly occurs a local pachymen- 
ingitis, which prevents the spreading of the disease upon 
the dura mater. Pus may find its way into the naso- 
pharynx or beneath the tissues about the auricle. 

If caries or necrosis attacks the mastoid antrum or the 
mastoid cells, there are pain, sw^elling, and infiltration of the 



DISEASES 01' 77/ K MIDDLE EAR 4C9 

skin at the posterior inner portions of the meatus. At first 
hard, the swelling becomes soft and fluctuating when pus 
forms. Pain is often severe, of a boring character, and 
worse at night. The discharges are usually abundant and 
characteristically fetid, due to the presence of saprophytic 
bacteria. 

In necrosis involving the labyrinth there is often nausea, 
vertigo, and a tendency to fall toward the affected side, 
the fluids of the labyrinth may escape, producing total deaf- 
ness. Temperature varies from slightly above normal to 
105° F. in the more acute cases. In the absence of tem- 
perature the leukocytes are less than normal and ane- 
mia is usually present. Polymorphonuclear leukocytes 
are found in cases of rapid necrosis and high temperature. 

The necrosed bone in the more chronic cases is usually 
imbedded in exuberant granulations, through which a probe 
detects, by the sensation of a rough surface, necrosed bone. 
If a cotten-tipped probe is used the rough surface catches 
in the fibers of cotton, producing a characteristic sensation. 

Treatvicnt. — If a sequestrum has formed it should be re- 
moved with forceps. Politzer's forceps (Fig. 206 ) are 
usually strong enough for this purpose, but Sexton's 
foreign-body forceps can often be used to better advantage. 
If it be found impossible to remove the sequestrum through 
the auditory canal because of the granulations and polypi 
that obstruct the canal, they should be removed by means 
of a snare ; after a few days, in some instances, the seques- 
trum will have been pushed outward by the granulations 
behind it into a position where it can readily be grasped by 
forceps and removed. 

In cases of caries or where the necrotic process has not 
progressed to the formation of a sequestrum, the diseased 
bone should be scraped away by means of a sharp curet 
and the parts covered with powdered boric acid. When ca- 
ries or necrosis affects the promontory, only the most super- 
ficial cureting is justifiable, but the parts should be kept 
scrupulously clean and as dry as possible by means of fre- 
quent insufflations of powdered boric acid. Cases where 
necrosed bone can be felt in a portion of the tympanum in- 
accessible to the curet are best treated by instillations twice 



410 DISEASES OF THE NOSE, THROAT, AND EAR 

a day of enzymol (Formula 13), a preparation containing 
pepsin. By this means the middle ear is, as it were, con- 
verted into a stomach capable of digesting the dead bone. 
Pepsin, of course, has no effect on living tissue. The ear 
should first be cleansed by syringing with warm water. 
The patient should then lie down with the diseased ear upper- 
most and fill the canal full of enzymoL By pressing the 
tragus inward a few times with the finger-tip the fluid is Syr- 
inbred, as it were, back and forth as far as the aditus and antrum. 
The excess of fluid is allowed to escape when the patient 
assumes the erect posture. Several hours are required for 
pepsin to produce its effect as a digestant and the presence 
of granulations may prevent its coming into contact with 
dead bone. It is well, therefore, after enzymol has been 
used for a few days, to employ instillations of alcohol for a 
day or two. 

The prognosis, of course, varies according to the part of 
the tympanum attacked by necrosis. In individuals other- 
wise healthy the prospects of a favorable result are en- 
couraging, even when a large portion of the temporal bone 
is involved by the disease. In tuberculous individuals, 
however, the disease sometimes progresses toward a fatal 
termination notwithstanding all efforts to prevent it. The 
prognosis is doubtful where there are symptoms of intra- 
cranical involvement, pyemia, or metastatic abscess. Fatal 
hemorrhage may occur from the carotid when its bony canal 
is involved. The rupture of the vessel usually occurs at 
" Hassler's site of predilection," that is, at the knee of the 
carotid in the bony canal, where it abruptly changes its 
course from the vertical to the horizontal. 



SYSTEMIC DISEASES CAUSING OTIC INFLAMMATION* 

The systemic diseases most frequently causing otitis are 
scarlet fever, measles, diphtheria, la grippe, typhoid fever, 
pneumonia, syphilis, tuberculosis, and diabetes. 

The appearance of otic inflammation in most of these 
diseases is a very serious complication, and although the 
subject has been already discussed in sections on the eti- 
ology and pathology of the various forms of otitis, it seems 



I 



DISEASES OE THE MIDDLE EAR 4II 

best to state briefly the peculiiirities of the otitis rcsultin^j 
from these systemic diseases and the modification of treat- 
ment necessary. 

Scarlatina. — The middle ear is frequently involved during 
scarlet fever. In some cases the inflammation seems to be 
simply catarrhal in character, probably due to closure of the 
Eustachian tube rather than the actual presence of the mi- 
cro-organism causing the disease. Such cases run a mild 
course. There may not be perforation of the membrana. 
The deafness resulting in those cases where no perforation 
has occurred is often considerable. 

When the ear complication occurs during the eruptive 
stage of scarlet fever it usually assumes a severe purulent 
type. The membrana and ossicles may come away as a 
slough in a surprisingly short space of time and, finally, 
large sequestra of bone. The purulent inflammation may 
involve the labyrinth, with resulting total deafness, or the 
facial nerve, causing facial paralysis. 

There is one practical point the practitioner should 
never forget, which is that the contagion sometimes lin- 
gers for several months in the discharge from the ear, and 
that a child with scarlatinal otorrhea may be the source of 
infection to other children. 

The treatment of scarlatinal otitis differs in no respect 
from that of otitis from other causes, providing the condi- 
tion of the patient will permit of its being carried out. The 
nose and throat should be cleansed once a day by the med- 
ical attendant with an atomizer containing Dobell's solution. 
The nose, if stenosed, should then be sprayed with adrenalin 
solution (i : 5000) to overcome the stenosis and, finally, the 
mucous membrane covered with the spray of menthol-cam- 
phor-albolene and powdered calomel. 

The ears should then be politzerized and, if discharging 
gently, syringed with a saturated boric acid solution and a 
piece of iodoform gauze placed loosely in the meatus. Every 
other day sublimate solution (i : 2000) may be substituted 
for the boric acid solution should the gravity of the case 
seem to require it. 

In some cases the patient, especially if a child, will be too 
weak or indocile to permit of so lengthy a treatment, and 



412 DISEASES OF THE NOSE, THROAT, AND EAR 

the practitioner may have to content himself with simply 
syringing with boric acid and subHmate solution. 

Sequestra of necrosed bone, polypi, mastoid complica- 
tions, and intracranial involvement, if the condition of the 
patient permit, should be treated in the manner described in 
other sections. 

Measles. — The ear is usually affected in measles, but with 
less virulence than in scarlatina. The condition is usually 
that of the catarrhal type, acute or subacute. Rarely does 
perforation occur. 

Treatment is the same as in similar types of otitis from 
other causes. 

Diphtheria. — Otitis media purulenta is not very infrequent 
in diphtheria. When the drum is perforated pseudomem- 
branes may extend from the middle ear onto the excoriated 
skin of the canal. In those with otorrhea, diphtheritic 
pseudomembranous infection may occur in the tympanum 
if they are brought into contact with diphtheritic patients. 

Treatment is similar to otitis from other causes. When 
the membrana has ruptured and a pseudomembrane is visi- 
ble the condition should be treated as described in the sec- 
tion on Diphtheria of the Meatus. 

La Grippe. — Aural complications in epidemics of influenza 
are very frequently encountered. Minute hemorrhages into 
the drum-head or beneath the epidermis of the canal are 
not infrequently encountered and are somewhat character- 
istic of the disease. 

The aural complications vary from a subacute catarrh, 
from which recovery takes place within a short time, to 
severe otitis media purulenta with intracranial complications. 
The possible gravity of an aural complication in a case of 
influenza should not be underestimated, and such a case 
should receive the most careful attention from its onset. 

The treatment is similar to otitis from other causes. 

Typhoid Fever. — The hebetude and apparent deafness of 
typhoid is due to the effect of the toxins of the disease on 
the internal ear. Occasionally internal-ear impairment of 
hearing is encountered years after recovery from the fever. 

Purulent inflammation of the middle ear is the result of 
invasion of the bacterium coli into the middle ear. Day 



DISEASES OE THE MIJ)DLE EAR 413 

and Jackson, of Pittsburg, describe three types of purulent 
otitis in typhoid — the hemorrhagic, the slow, and the ful- 
minating. The disease is usually rapid in its onset and 
characterized by intense pain. Day and Jackson state that 
in 10 cases no otitis was manifest one or two days previous 
to spontaneous rupture of the membrana. 

In the Medico-Chirurgical Hospital during the Spanish 
war, of 268 soldiers sick from typhoid fever 3 had severe 
otitis media purulenta as a complication of the disease. 

The ear compUcations of typhoid occur usually in the 
third or fourth week. The symptoms vary from those of 
subacute catarrh to the severe form of middle-ear suppura- 
tion. Hemorrhagic blebs similar to those encountered in 
aural influenza have been observed by Day and Jackson 
previous to rupture of the drum-head. 

The treatment is that of otitis elsewhere when the condi- 
tion of the patient will permit. The danger of heart failure 
from sitting up in bed, and nasal hemorrhage as the result 
of using the spray and Politzer bag should be borne in mind. 
A troublesome nasal hemorrhage apparently did originate 
in one of the cases treated in the Medico-Chirurgical Hos- 
pital from the use of the atomizer. In some cases, for a few 
days at least, it is best to be content with simply syringing 
the meatus with boric acid solution twice a day and inserting 
a little iodoform gause loosely into the concha. It is better 
to avoid inserting gauze into the canal, especially if the 
dressing be entrusted to a nurse, for fear that the gauze will 
become impacted from some cause, possibly the finger of 
the patient. The gauze should be changed as often as it 
becomes saturated. Pressure-pain with bulging of the drum- 
head will indicate paracentesis. 

Tuberculosis of the middle ear is probably always second- 
ary to phthisis. Tuberculous deposits occur in the middle 
ear, which, after a time, break down, causing more or less 
rapid destruction of tissue. The most marked symptom is 
the painless cJiaracter of the otitis media purulenta that 
results in perforation of the membrana. After a considerable 
destruction of the drum-head has occurred the parts not 
infrequently become sensitive, probably as the result of 
mixed infection. Ordinarily the disease pursues a chronic 



414 -DISEASES OF THE NOSE, THROAT, AND EAR 

course and the otorrhea may even cease for a time and 
reappear. 

Sometimes the destruction of tissue is rapid and the dis- 
ease extends to the mastoid, necessitating operation. Caries 
of the bone may involve the facial nerve and cause facial 
paralysis or the internal ear may be invaded. Pus, in the 
more severe forms of the disease, is abundant and fetid, but 
tubercle bacilli are not usually numerous nor easy to find 
in the discharges. 

It should be borne in mind in this connection that otitis 
media purulenta may occur in a tuberculous individual 
without the disease being due to tuberculosis. 

Treatment. — The general treatment is of primary impor- 
tance and consists of a diet largely of milk and raw eggs, 
outdoor life, and tonics. Local treatment is usually not very 
successful in bringing about a cessation of the discharge. 
The parts, however, in middle-ear suppuration should be 
kept clean, either by the dry method or by syringing with 
boric acid and sublimate solution. It should be borne in 
mind that the discharges are contagious and care should be 
exercised to destroy all dressings used about the ear. 

Pneumonia. — As in typhoid, otitis media purulenta gener- 
ally occurs late in the disease, if at all. The pneumococcus 
is not infrequently found in the pus of an otorrhea occur- 
ring independent of pneumonia. 

The treatment is the same as in otitis occurring from other 
causes. 

Syphilis. — The middle ear is frequently inflamed during 
the period of secondary skin rashes and sore throat. In a 
case observed by the author facial paralysis occurred. The 
middle ear may become the seat of a gumma in the tertiary 
period of the disease. The symptoms at first are those of 
pressure within the middle ear, deafness, tinnitus, and some- 
times vertigo. Sooner or later suppuration with perforation 
of the membrane occurs, and the disease assumes the ap- 
pearance of chronic otitis media purulenta. The destruction 
of tissue is often considerable. 

Treatment. — The local treatment is that of otitis ; the 
constitutional treatment being of greater importance. In 
cases where the diagnosis of gumma is made early, inunc- 



I 



OPERATIONS UPON THE MIDDLE EAR 415 

tions of mercury with iodid of potassium internally may 
result in absorption of the gumma before it breaks down. 

Blight's Disease. — In advanced Brii^ht's disease all opera- 
tions under a general anesthetic about the nose, throat, and 
ear are dangerous because of the possibility of fatal coma. 

Diabetes. — Recurrent furunculosis of the canal may result 
from glycosuria. Mastoid wounds and large wounds about 
the upper respiratory tract do not heal as rapidly in w^ell- 
marked glycosuria as in a normal individual, and otitis 
media purulenta runs a more severe course with greater 
destruction of tissue. 



OPERATIONS UPON THE MIDDLE EAR 

Operations are performed upon the middle ear for the 
improvement of hearing, the relief of tinnitus aurium or 
vertigo, and to bring about the cure of a persistent discharge 
from the middle ear. 

The operations that have been performed from time to 
time are quite numerous, the following being a partial list: 
Paracentesis^ single or multiple ; excision or destruction by 
caustics of a portion of the membrana tympani for the pur- 
pose of establishing a permanent opening ; plicotomy or divi- 
sion of the posterior fold ; section of the anterior ligament 
of the malleus ; tenotomy of the tensor tympani or stapedius 
muscle, or both ; division of adhesions between the mem- 
brana and promontory or between the ossicles, etc. ; excision 
of a portion of the membrana ; disarticulation of the incudo- 
stapedial articulation or division of the descending process 
of the incus and mobilization of the stapes ; plastic opera- 
tions for uniting either the incus or stapes with the mem- 
brana tympani ; and removal of one or more of the ossicles. 

Myringotomy is performed for the evacuation of fluids from 
the cavity of the tympanum or as an exploratory incision to 
determine the mobility of the stapes before attempting a 
more radical operation. When the operation is done for 
the evacuation of fluids, the cut is generally made in the 
posterior inferior quadrant, and it should be at least 2 or 3 
millimeters in length. The exploratory incision, which is 
made from just behind the short process, should extend im- 



4l6 DISEASES OF THE NOSE, THROAT, AXD EAR 



mediately beneath the posterior fold for a sufficient distance 
to cause considerable gaping of the wound, and to allow the 
operator to test the mobility of the stapes and observe the 
condition of the tympanum (Fig, 231). The operation does 



in 



u 



ri 



i 



/ \ 



■®n^ 



n\ 



Fig. 229. — Dench's set of ear instruments. 



not usually require general anesthesia, but cocain and adre- 
naHn may be injected beneath the skin of the canal by 
Ballin's method (Formula 20). The hearing should be 
tested before and after the operation and any improvement 
noted. The wound of the exploratory incision is brought 
together and is held in position by the insufflation of a small 
quantity of boric acid. 



OPERATIONS VPOX TI/E MIDDLE EAR 4I7 

Methods of Producing a Permanent Opening in the Mem- 
brana Tympani. — A portion of the nicnibranc maybe excised 
with a knife (Fii;". 229, e) or reinoved by tlie method of 
Simrock. A minute portion of concentrated sulphuric acid 
is held against the membrana at the desired spot by means 
of a cotton-tipped probe. The acid immediately attacks the 
membrane and destroys that portion with which it is brought 
into contact, so tliat in the course of a few moments an 
opening can be made by pushing a blunt probe through the 
eschar. But little reaction commonly follows the operation, 
and the opening generally remains patulous for some time 
if it is let aloiic, and in some cases produces considerable 
improvement of the acuteness of hearing. A little pow- 
dered boric acid should be insufflated upon the parts as 
a dressing after the operation. 

Multiple Incisions of the Membrana Tympani and Tenot- 
omy of the Tensor Tympani. — These operations have been 
performed for improvement of the hearing and for the relief 
of tinnitus. But temporary improvement can be expected 
as the outcome of either operation. Section of the tensor 
is probably best performed in the following manner: An 
angular knife (Fig. 22g,f or g) is thrust through the mem- 
brana tympani close in front of, or immediately behind, the 
malleus handle, and just below the short process. Section 
of the tendon is accomplished from below upward, the cut 
through the membrana being extended upward at the same 
time. The tenotomy should be followed by a vigorous 
inflation of the tympanum by Politzer's method, in order, 
if possible, to restore the drum-head to its normal posi- 
tion. 

Removal of the Membrana Tympani, Malleus, and Incus 
in Chronic Catarrh of the Middle Ear. — The operation is 
performed for the relief of tinnitus and to improve hearing 
when milder measures have failed to check the progress 
of the disease or secure relief from tinnitus. Before deter- 
mining the advisability of operating, the hearing should care- 
fully be tested by means of tuning-forks. If it is found that 
the acuteness of hearing has been seriously impaired, largely 
as the result of impairment of the functions of the laby- 
rinth or auditory nerve, but little if any improvement of the 
27 



41 8 DISEASES OF THE NOSE, THROAT, AND EAR 

hearing power can be expected as the result of the opera- 
tion. 

TecJinic. — Perfect control of the patient should be secured 
by the administration of ether, and the operation should be 
performed with antiseptic precautions. The auditory canal 
should first be cleansed thoroughly and syringed with a 
strong bichlorid solution. An electric lamp attached to the 
forehead (Fig. 230) will be found a convenient means of illumi- 
nating the field of operation, although some operators prefer 
dayhght reflected into the canal by means of the forehead 
mirror. The advantage of the arrangement shown in the fig- 
ure is that the lantern, containing an ordinary 2- or 3-candle, 




Fig. 230.— Gleason's electric light for intratympanic surgery. 

4- to 6-volt lamp, can be attached in place of the reflector to 
the head-band the aurist is accustomed to wear ; and if the 
electric light within the lantern burns out during an opera- 
tion it can almost instantly be replaced by a new one. In 
combination with a small 3-cell storage battery it yields a 
2 to 3 candle-power light for one and a half hours, and is 
an extremely light and portable outfit. In a very light room 
2 or 3 candle-power lamps are not entirely adequate, but by 
means of a current controller lamps of any candle power 
up to 8 may be employed. Suitable lamps for this purpose 
can be obtained in almost any electric supply store. Unfor- 
tunately, in the course of fifteen or twenty minutes, the appa- 



OPERATIONS UPON 77/ K MI7)DLE I'lAK 419 

ratus becomes too hot for comfort if touched with the hand 
when lamps of 8-candle power arc used. However, most 
operations on the middle car do not require a very bright 
lifjht for a loni^ period, and when the current is turned off 
the apparatus quickly cools. An adjustable lensc focuses 
the light upon the field of operation and is sufficiently bril- 
liant to be of value in a room into which the sunlight pene- 
trates. 

An incision is first made through the membrana, com- 
mencing at a point posterior to the short process and fol- 
lowing a curve just below the posterior fold until the middle 
of the posterior part of the ring is reached. If the incision 
has been made carefully with a sharp knife in the clear part 
of the membrana no bleeding will occur ; when the flap is 
pressed downward there will be brought into view the 
incudostapedial articulation, which is next divided by means 
of an angular knife (Fig. 22g,f or g) passed into the tym- 
panum, either in front of or behind the incus shank. By 
slight traction outward the knife is made to hug the incus 
shaft, while at the same time the articulation is divided by 
a downward stroke. Care should be exercised that the 
articulation is thoroughly divided before attempting any 
further manipulations. A puncture should now be made 
with the sharp knife (Fig. 229, d) through the membrane 
at its lowest portion, sufficiently large to permit the intro- 
duction of a probe-pointed knife (Fig. 229, c), w^hich is 
made to cut its way upward until the inferior extremity of 
the original incision is reached. The blade of the knife is 
now turned in the opposite direction and the membrana 
is incised anteriorly up to the anterior fold. Up to this 
point httle or no bleeding will occur to obscure the field of 
operation. 

The next step is to divide the attachments of Shrapnell's 
membrane and the strong anterior ligament of the malleus. 
This should be done rapidly, as the hemorrhage will be 
somewhat profuse. The sharp-pointed knife (Fig. 229, c), 
with its handle depressed until it touches the low^er margin 
of the speculum, is made to pierce Shrapnell's membrane 
just above the short process, and is thrust inward and 
upward into the fornix tympani, and is then made to cut its 



420 DISEASES OF THE NOSE, THROAT, AND EAR 

way out downward and backward, thus severing the external 
and posterior hgaments of the malleus and the posterior 
portion of the membrana flaccida. The knife is then quickly 
turned, its point carried over the short process, and made to 
cut through the anterior segment of Shrapnell's membrane 
and the strong anterior ligament of the malleus. As soon 
as the hemorrhage, which may obscure the field of opera- 
tion, has been checked, the malleus is grasped with Sexton's 
foreign-body forceps, and, being first pressed inward to free 
its head from the ledge on which it lies, is brought down 
and extracted. The superior ligament and the tendon of 
the tensor tympani both being weak no force is necessary to 
rupture them. 

After the somewhat free hemorrhage following the extrac- 
tion of the malleus has been controlled and the blood removed 
by means of absorbent cotton wrapped about a probe, the 
incus, if in sight, is seized with the forceps and removed, 
traction being exerted first inward, then downward and out- 
ward. Frequently the shank of the incus will not be in 
sight, having been displaced downward and backward during 
the removal of the malleus. Under these circumstances it 
is sought for by means of the curved probe (Fig. 229, k or /). 
The end of the probe is carried into the tympanum with its 
curve directed backward and then rotated upward, until the 
incus is brought into view. The maneuver will perhaps 
have to be repeated several times before this result is accom- 
plished. 

After the operation all blood should be removed from the 
tympanum and canal by means of absorbent cotton wrapped 
about the end of a probe and a plug of iodoform gauze loosely 
inserted in the auditory canal. 

Many operators advise the removal of the incus before 
the malleus. If, after the incudostapedial articulation has 
been severed, the incus shank is clearly discernible, it is best, 
in most instances, to at once grasp and remove it with a 
suitable pair of forceps, thus avoiding the necessity of 
searching for and perhaps being unable to discover it at a 
subsequent stage of the operation. Before closing the audi- 
tory canal with gauze it is best in all instances to test the 
mobility of the stapes. If this bone is bound down by 



OPERATIONS UPON THE MIDDLE EAR 42 I 

adhesions they should be severed, and if the adhesions are 
so extensive as to render it probable that they will so re- 
form as to interfere with the mobility of the stapes, the head 
of this bone should be f^rasped with forceps and extracted 
or it may be removed by means of a hook. Great care 
should be exercised not to dislocate the bone inward into 
the labyrinth while executing these maneuvers. 

After the operation the tympanum should be dried with 
absorbent cotton and lightly dusted with iodoform, and the 
tympanum and canal very loosely packed w^ith a narrow 
strip of iodoform gauze in order to check any oozing and 
to serve as a drain. The packing is removed at the end of 
twenty-four hours and, if necessary, another strip of iodo- 
form gauze inserted, after cleansing and drying the parts by 
means of absorbent cotton wrapped about the end of an 
Allen probe (Fig. 35). Further treatment will depend upon 
the amount of reaction following the operation. Rarely, 
severe pain occurring a few hours after the operation requires 
the removal of the packing and very gentle syringing with 
hot distilled water to which boric acid or carbolic acid may 
be added. The ear should be protected by means of a 
pledget of absorbent cotton placed loosely in the canal, and 
should be changed by the patient if it becomes saturated 
with discharge. The parts should be inspected once a day 
by the surgeon, and if no discharge is present the middle 
ear at least should not be disturbed. If, however, there be 
a discharge, the parts should be gently but carefully 
cleansed by means of absorbent cotton dipped in a solution 
of peroxid of hydrogen and a little powdered boric acid 
dusted over the parts after they have been thoroughly dried. 
A slight serous discharge for a few days after the operation 
is not uncommon, but suppuration rarely occurs. Vertigo 
and nausea are generally complained of for a few days if 
the stapes has been roughly manipulated or removed. 

Prognosis.— -TmmXMS is usually at least alleviated, but the 
results as regards the hearing are so uncertain that there 
has been a growing disposition manifested to abandon this 
operation for simpler procedures. The operation has the 
advantage of permitting free access to the tympanum for 
subsequent mobilization of the stapes or the division of ad- 



422 DISEASES OF THE NOSE, THROAT, AND EAR 

hesions should it be necessary. Ordinarily the drum-head 
is replaced, in whole or in part, by cicatricial tissue, which, 
if it interferes with the acuteness of hearing, will require 
removal, the operation being repeated as often as necessary ; 
while the absence of the drum-head permits the entrance of 
dust and other materials into the middle ear, which conse- 
quently may readily become infected. Apparently the idea 
that the presence or absence of the membrana tympani 
greatly increases or decreases the hearing when the Eusta- 
chian tube is patulous is a myth, but the chief function of 
this structure — namely, the exclusion of dirt from the mid- 
dle ear — is of the greatest importance, and should not be 
impaired by an operation for the relief of deafness and tin- 
nitus unless absolutely necessary. In many instances 
equally good results, as far as the relief of tinnitus and the 
improvement of the hearing are concerned, can be secured 
by severing the incudostapedial articulation and mobilizing 
the stapes — with or without tenotomy of the stapedius 
muscle. 

Severing the Incudostapedial Articulation and Mobilizing or 
Extracting the Stapes.— A general anesthetic may be admin- 
istered, but it is preferable to operate under cocain anesthesia 
in order to secure the co-operation of the patient and to test 
his hearing from time to time during the different stages of 
the operation. The field of operation is prepared, upon the 
preceding day, by carefully cleansing the auditory canal 
with a solution of peroxid of hydrogen and syringing with 
a I : 2000 solution of corrosive sublimate, after which the 
auditory canal is stopped with a plug of iodoform gauze. 
All instruments, the absorbent cotton, and the solutions of 
cocain are sterilized in the usual manner by heat. Anesthe- 
sia is secured by the method of Ballin, which consists in 
subcutaneous injection into the roof of the canal of a mix- 
ture of equal quantities of a i per cent, solution of cocain 
and a i : looo solution of adrenalin (Formula 20). 

TccJinic. — Commencing rather below the middle of the 
posterior periphery of the drum-head, an incision is made 
and prolonged upward with the probe-pointed knife (Fig. 
229, <f) through the clear portion of the drum-head close to 
the annulus, beneath the posterior fold, and for a short dis- 




Ol'ERATIONS UPON' 77//-: MI 1)7)7,7''. 7wt /^ 423 

tancc downward alonj^lhc malleus handle (I'^ii^. 23 i). Little 
more than a fraction of a drop of blood ordinarily follows 
the incision, but the flap should be turned forward, and a 
plcdc^et of absorbent cotton wrapped about the end of an 
Allen probe and saturated with a solution of adrenalin 
should be held in contact with the cut surfaces and the tym- 
panic mucous membrane until all bleeding^ has ceased. Be- 
fore proceeding further with the operation it is well to test 
the patient's hearing; with both the voice and the watch, in 
order to ascertain if any improvement in 
the hearing has resulted from the artificial 
opening in the drum-head. This is rarely 
the case. 

Generally when the flap is turned for- 
ward it remains in that position, and a 
good view of the interior of the drum is 
obtained. If this is not the case, the in- 
cision should be continued downward 

1 ,, ,.1 1 r .^ 11 through the drum-head. 

along the posterior border 01 the malleus 
handle until the flap does not tend to close the wound and 
obstruct the view. The region of the round window should 
be carefully inspected and any abnormality noted and reme- 
died, if possible, at a subsequent stage of the operation. If 
the incudostapedial articulation is not visible it is brought 
into view by inclining the patient's head strongly toward his 
opposite shoulder so that it is possible to see upward be- 
neath the posterior fold. The incus-hook (Fig. 229, b) should 
now be passed around the descending process of the incus 
close to the stapes and an effort made to mobilize the 
ossicles by gentle traction in anterior, posterior, and lateral 
directions, and any improvement in the patient's hearing 
noted. If none occurs, the tendon of the stapedius muscle 
should next be divided with the point of the sharp-pointed 
knife (Fig. 229, c) by a downward stroke close behind the 
incudostapedial articulation. Sometimes the tendon gives 
way with an audible snap and immediate improvement in 
the patient's hearing follows. If, however, the hearing is 
not improved the incudostapedial articulation should be 
severed by means of an angular knife (Fig. 229, f or g)^ 
which is made to cut downward through the joint either from 



424 DISEASES OF THE NOSE, THROAT, AND EAR 

in front of or behind the incus-shank, which it hugs closely 
while the downward stroke or strokes are being made. If 
the knife cannot readily be passed beyond the incus-shank, 
either in front of or behind it, the joint may be severed from 
below with the point of the knife. The knives (Fig. 229,/ 
and g) are not double edged, because it is difficult to sharpen 
a knife of that character so that it will cut through the 
incudostapedial articulation readily without employing more 
force than is ordinarily judicious. After the incudostapedial 
articulation has been severed the incus-shank is pushed for- 
ward and upward in order to diminish the possibility of its 
tip reuniting with the stapes. After severing the incudo- 
stapedial joint, if the patient's hearing still remains unim- 
proved, the point of the sharp-pointed knife may be 
cautiously carried about the head of the stapes, within the 
pelvis of the oval window, and an attempt made to mobilize 
the stapes by means of an Allen probe about the end of 
which a few fibers of cotton have been wrapped. . The 
head of the stapes should be gently pressed upward, 
then backward, then forward, care being exercised that 
sufficient force is not employed to endanger fracturing the 
crura of the stapes, which, as the result of atrophic changes, 
are sometimes very fragile. If, in spite of these manipula- 
tions, the bonelet remains firmly fixed and the patient's hear- 
ing unimproved, an attempt may be made to remove the 
ossicle by traction with a hook. If bony ankylosis exists 
between the foot-plate of the stapes, Politzer has shown by 
experiments on the cadaver that the effort will not succeed, 
but that the crura will be fractured in the effort to remove 
the stapes. A portion of the foot-plate may, however, be 
removed with the fragment of the crura of the stapes and 
the patient's hearing improved, at least for a time. 

After the completion of the operation the edges of the 
wound in the drum-head are brought together and supported 
by a small amount of boric acid or iodoform insufflated by 
the powder-blower. Ordinarily the edges of the wound 
quickly unite, but suppuration has been reported as follow- 
ing the operation in a few instances. 

Pi'ognosis. — In all intratympanic operations the prognosis 
is uncertain. Good results have been reported by numerous 



OPERATIONS UPON TJIE MIDDLE EAR 425 

operators as following severing the incudostapcdial articu- 
lation and mobilizing the stapes with or without the removal 
of the incus. The prognosis as regards diminishing tinnitus 
is much better than that of improving the hearing to a use- 
ful degree.^ 

From the published reports intratympanic operations 
seem remarkably free from risk. In several instances, how- 
ever, persistent suppuration has followed intratympanic 
operations in catarrhal cases. A slight amount of serous 
discharge for a few days after the operation is not unusual. 
In I case reported by Randall the unintentional dislocation 
of the incus backward into the antrum was followed by 
mastoid abscess requiring surgical interference. Both Lude- 
wig and Dench have reported cases in which the facial nerve 
has been injured by the incus-hook, with resulting tempo- 
rary facial paralysis. 

Theoretically, the removal of the stapes would seem to 
leave the way open for infection of the labyrinth from the 
tympanum. When the operation is performed in suppura- 
tive cases the danger is apparent, and the fact that no cases 
have been reported is probably the result of the careful 
asepsis observed. 

It seems probable that in most instances the impairment 
of hearing and tinnitus is due in catarrhal cases to immo- 
bility of the stapes, and that the improvement as regards 
tinnitus and hearing in removal of the drum-head and larger 
ossicles has resulted from intentional or unintentional mo- 
bilization of the stapes while severing the incus from the 

1 Of 12 cases operated upon by the author, tinnitus when present disappeared 
or was greatly alleviated in all, but hearing was only greatly improved in 4, 
In some of the cases vertigo followed the operation, persisting for a few hours, 
and in one instance for about three days. In i case — that of a bleeder — 
hemorrhage prevented completion of the operation, but the drum-head was 
subsequently opened by Simrock's method and the incudostapcdial articulation 
severed, with the result of greatly alleviating tinnitus and slightly improving 
the hearing for the voice. In none of these cases was hearing for the watch 
permanently improved. In I of the 1 2 cases the crura of the stapes and a 
portion of its foot-plate were removed. In this instance nausea and vomit- 
ing followed the operation and persisted for three or four days. Vertigo also 
caused considerable discomfort for two or three weeks. The hearing for con- 
versation, at first greatly improved, greatly declined, until at the end of two 
years the improvement, at first manifest to both the patient and her friends, 
became by no means so apparent. Tinnitus entirely disappeared. 



426 DISEASES OF THE NOSE, THROAT, AND EAR 

stapes. It also appears probable that in most instances any 
improvement will not be permanent. Stapedectomy was 
theoretically a promising operation, but the results are dis- 
appointing, owing to the fact that in true bony ankylosis 
the crura are usually broken off in the effort to remove the 
ossicle, and only a portion, if any, of the foot-plate is 
brought away. Even in fortunate results following the 
operation the improvement could scarcely be permanent, 
because the progress of the disease is not prevented by the 
removal of the stapes. In a case of chronic otorrhea the 
author, while searching for a polypus in the attic or other 
cause of the continued discharge with Allport's curet forceps 
(Fig. 235), inadvertently removed the stapes. The patient 
had slight vertigo for some days after the accident, but the 
hearing (about |^ for the watch) was neither impaired nor 
improved during the eight years that have elapsed since the 
occurrence ( 1899). Politzer has shown that the cause of bony 
ankylosis of the stapes is a " circumscribed primary affection 
of the labyrinthine capsule, exhibiting post mortem, in the* 
region of the niche of the oval window, more or less sharp 
bony protuberances, covered mostly with normal mucosa, the 
neoplastic bony tissue gradually pushing aside the normal 
bone and attacking the oval window and stapes, producing 
ankylosis of the stapes. The round window may also be 
very much contracted." 

This contribution of Politzer to our knowledge of the 
pathology of so-called " dry catarrh of the middle ear " is 
most important and fully explains the poor success follow- 
ing intratympanic surgery in such cases. Politzer regards 
the prospect of curing the disease as nearly hopeless, but 
thinks that its rapid progress might be stayed by the local 
use of iodin vapor and the internal administration of iodid 
of potassium. 

It will readily be seen that the pathology of the ossicular 
articulations in this disease is somewhat similar to that of 
rheumatic or gouty joints in other parts of the body — a 
fact to which Wilde ^ and Toynbee ^ half a century ago 
called attention. 

1 Diseases of the Ear, by William R. Wilde, pp. 222, 242, 233- 

2 Ibid., by Joseph Toynbee, 2d Amer. ed., p. 298. 



OPERATIONS UPON THE MIDDLE EAR 427 

Operations for the relief of deafness and tinnitus resulting 
from chronic suppuration of the middle ear arc division or 
divulsion of false membranes and adhesions binding the 
ossicles together or to the tympanic walls in such a manner 
as to interfere with the vibration of the stapes ; mobilization 
or removal of the stapes ; removal of the remains of the 
drum-head and the two larger ossicles. 

In most instances the first ossicle to become carious or 
necrosed as the result of chronic intratympanic suppuration 
is the incus, because of its imperfect blood-supply as com- 
pared with that of the other intratympanic structures. The 
entire bonelet may disappear as the result of a few weeks 
of intratympanic suppuration. Ordinarily the descending 
process is the first portion of the incus to disappear, thus 
freeing the incus. The comparatively good hearing of 
patients with large dry perforations of the membrana is due 
in many instances to the fact that the stapes is thus freed at 
an early stage of the suppurative process, and does not be- 
come involved by subsequent contractions and adhesions. 
In some instances, however, this fortunate result does not 
occur, and the detached stapes may be completely buried 
in a mass of cicatricial tissue which holds it immovable in 
the pelvis of the oval window. When not detached from 
the incus the movements of the stapes may be interfered 
with by bands of tissue binding the two larger ossicles 
together or to the tympanic wall. The most common of 
such bands is one extending from the long process of the 
incus to the tympanic wall and the malleus handle (Fig. 

Division or divulsion of such bands is in some instances 
followed by the most astonishing improvement in the hear- 
ing power and the complete relief of tinnitus. In suitable 
cases more permanent results are secured by divulsion or 
stretching of the bands than by cutting them. In some 
cases the vibrations of the ossicular chain are interfered with 
by an adhesion of the remains of the drum-head to the 
promontory in such a manner as to bind down the malleus 
handle. Under such circumstances division of the adhesion 
is followed by improved hearing and decreased tinnitus. 
In most instances divulsion of intratympanic bands and 



428 DISEASES OF THE NOSE, THROAT, AND EAR 

adhesions will have to be repeated from time to time in 
order to secure permanent results ; but as the operations 
are by no means formidable, when required they may be 
done during an ordinary office visit. In the divulsion of 
bands and adhesions care should be exercised that sufficient 
force is not employed to endanger dislocation of one of the 
ossicles, more especially the stapes. After division of 
synechiae and surgical mobilizing of the stapes the hear- 
ing power can sometimes be increased by the use of an 
artificial drum-membrane ; for this purpose a membrane 
made of paper, as first employed by Blake, answers an ad- 
mirable purpose, and is sometimes followed by so much 




Fig. 232. — A, Band of connective tissue extending from the long process of the incus, 
C, to the malleus handle, B, which was adherent to the promontory. Hearing for the watch 
increased from 2 inches to 2 feet as the result of divulsing this band by gentle traction with 
an Allen probe, the point of which was bent nearly at a right angle and inserted underneath 
the band. The improvement lasted for nearly three years, when the operation was repeated 
with equally satisfactory results. 

permanent improvement of the hearing that its use can 
finally be dispensed with. The permanent improvement is 
doubtless due to *'automobilization" of the stapes during 
hearing as the result of wearing the disk. 

The removal of the two larger ossicles, or what remains 
of them, is admissible as a means of improving the hearing 
or diminishing tinnitus ; but cases are hardly conceivable in 
which all the improvement possible, as regards both tinnitus 
and hearing, cannot be secured by the division of adhesions, 
disarticulation of the incudostapedial joint, or mobilization 
of the stapes. 

The history of intratympanic operations for the relief of 
deafness and tinnitus is somewhat interesting. The acci- 



OPERATIONS UPON TIIK MIDDLE EAR 429 

dental rupture of the drum-head havin<^ resulted in the im- 
provement of a deaf person's hearing, Ri(3lan proposed 
making an artificial opening in the membrana tympani as a 
remedy for deafness. Experiments upon dogs and other 
animals as to the effect of the excision of a portion of the 
drum-head having yielded inconclusive results, Cheselden, 
the flither of English surgery, wished to perform the opera- 
tion upon a criminal condemned to death, who was to obtain 
his release on account of it. In a foot-note Wilde ^ says 
that the case is referred to in Walpole's Reminiscences, 
where it is stated that the criminal was the surgeon's 
cousin ; and that he was actually pardoned through the in- 
tercessions of Lady Suffolk (mistress to George II.), who, 
being deaf, wished to have the experiment tried ; but the 
operation was not performed, owing to the popular outcry 
against it. 

In 1800, Mr. (afterward Sir) Astley Cooper published 
a letter in the Philosophical Transactions entitled " Ob- 
servations on the Effects which take place from the De- 
struction of the Membrana Tympani of the Ear," and 
soon afterward obtained a medal from the Royal Society 
on account of the success that, in a few cases, followed the 
operation of puncturing the drum-head for the relief of 
deafness. 

Toynbee^ says of the operation : *' In Sir Astley Cooper's 
successful cases there was simple obstruction of the Eus- 
tachian tube ; and there is little doubt that the affection 
would have yielded to simpler measures having for their 
object the removal of the obstruction, while the cure, instead 
of being temporary, would have been permanent. In the 
great majority of cases where Sir Astley Cooper punctured 
the membrana tympani not the slightest benefit accrued, 
because the deafness was dependent upon other causes than 
obstruction of the Eustachian tube ; and in some cases of 
deafness from debility of the auditory nerve the shock of the 
operation greatly aggravated the symptoms." 

In 1846, Dr. Butcher read a paper before the Dublin 
Surgical Society on the evil results of perforating the mem- 

^ Diseases of the Ear, by William R. Wilde, p. t^^. 
2 Ibid., by Joseph Toynbee, p. 240. 



430 DISEASES OF THE NOSE, THROAT, AND EAR 

brana, and reported two deaths as having apparently oc- 
curred as the result of the operation.^ 

Notwithstanding the fact that Sir Astley Cooper soon 
abandoned perforating the drum-head as a remedy for deaf- 
ness, his instruments and the technic of his operation were 
modified and improved by Himley, Itard, Delau, Fabrigi, 
and others ; while the operation became very common upon 
the continent of Europe, but was gradually nearly aban- 
doned there also. 

The operation of the removal of the drum-head, malleus, 
and incus was first done in America at New York, in 1886, 
by Samuel Sexton,^ and shortly afterward (1888) in Phila- 
delphia, by Burnett. The operation soon became very 
common and bad results multiplied. At the present time 
the operation for the removal of the drum-head, malleus, 
and incus in non-suppurative cases is in bad repute, and 
there is a disposition to abandon it entirely. Probably even 
those American aurists who have performed the operation 
most frequently would entirely agree with Schwartze, who, 
as the result of an experience of more than twenty years, 
during which time he has done the operation each year less 
and less frequently, merely says of it that it is not entirely 
contraindicated. 

In 1892, Jack^ reported the results of 16 operations for 
the removal of the stapes, and in the following year the 
results in 32 additional cases."* Both Jack and Blake, of 
Boston, have performed the operation somewhat frequently, 
but without uniformly beneficial results, the larger percent- 
age of good results being obtained in suppurative cases, 
where it is probable that in many of the cases operated upon 
an equally good result might have been secured by a simpler 
and less serious operation. Of the 21 cases of removal of 
the stapes in non-suppurative cases reported by Blake in 
1893,^ there was a noticeable improvement in the hearing 

1 Quoted by Wilde, p. 286. 

2 The Ear and it^ Diseases, by Samuel Sexton, p. 368. 

3 " Remarkable Improvement in Hearing by Removing the Stapes," by 
Frederick I.Jack, M. D., in Trans, of the Amer. Otological Society, 1892. 

* " Further Observations on Removal of the Stapes," Ibid., 1893. 
5 " Stapedectomy and other Middle-ear Operations," by Clarence J. Blake, 
Ibid., 1893. 



OPERATIONS UPON THE MIDDLE EAR 43 1 

in only 3 ; and only in 2 of these 3 was there improvement 
in the hearing- sufficient to be of any practical benefit. 

Conditions preventing the cessation of a chronic discharge 
from the middle ear are polypi ; a pulpy or granular condition 
of the mucous membrane ; insufficient drainage, because of 
a small perforation or one unsuitably situated ; necrosis of 
one or more of the ossicles or of the tympanic walls ; cho- 
lesteatoma. 

The treatment of polypi and granulations has already 
been described. 

In some instances, where a large perforation exposes 
swollen or granular mucous membrane upon the promon- 
tory, rapid cessation of a chronic discharge will be brought 
about by lightly touching the parts once or twice a week 
with a 25 per cent, solution of chloracetic acid in conjunc- 
tion with the treatment already advised for chronic suppu- 
ration. 

The mere presence of localized spots of necrosis or caries 
upon one of the larger ossicles is hardly a sufficient reason 
for its removal. Perfect cleanliness and good drainage is 
ordinarily sufficient to bring about a cure of the condition. 
The rubbing of the parts with a cotton-tipped Allen probe 
that has been dipped in peroxid of hydrogen, and proper 
daily intratympanic syringing will have a stimulating action 
upon the parts and will aid the proliferation of epithelium 
over the diseased area. If these measures fail, the malleus 
and incus should be excised to permit freer access to the 
attic and better drainage. 

When the attic has become epidermized, scales of epi- 
dermis will be exfoliated from time to time, until a little ball 
of cholesteatomatous material will have collected in the attic 
and perhaps have extended into the aditus as well. The 
disintegration of such masses is a common cause of chronic 
suppuration and the growth of polypi. In every case of 
long-continued suppuration the presence of cholesteatoma 
may be suspected. It is rare to fail to remove by intra- 
tympanic syringing of the attic cholesteatomatous scales in 
cases of long-continued middle-ear suppuration in which 
the discharge originates within this cavity. The removal of 
such little masses, and also the granulation-tissue or small 



432 DISEASES OE THE NOSE, THROAT, AND EAR 

polypi that their presence commonly causes, will in most 
instances be all that is necessary to bring about a cessation 
of a chronic discharge that may have persisted for years. 
Under such circumstances the hearing is often greatly 
improved. 

In most instances where it is necessary to resort to oper- 
ative procedures for bringing about a cessation of a chronic 
otorrhea, the mere removal of the remains of the two laro-er 
ossicles will not be sufficient, and it is far preferable to re- 
sort to Stacke's operation, which consists in chiseling away 
the posterior upper wall of the bony meatus in order to 
gain ready access to the attic, aditus, and, if necessary, the 




Fig. 233. — Vertical sag-ittal section through a left temporal bone ; median surface of the 
lateral portion. The mastoid antrum, aditus, and attic of the tympanum are filled by a 
cholesteatoma. The mastoid process is sclerosed and its pneumatic cells are few and 
small : A, Antrum containing- a portion of the cholesteatoma; i\[, auditory meatus. (From 
a photograph of a specimen in the author's collection.) 



mastoid antrum. Stacke's or some similar operation would 
certainly be necessary to bring about a cure of the chronic 
otorrhea resulting from a condition similar to that existing 
in Figs. 233 and 234, for it will be observed that the 
cholesteatomatous mass occupies the mastoid antrum as 
well as the attic, and it would be absolutely impossible to 
remove such a mass except through a comparatively large 
opening. It should be borne in mind, however, that no 
operative procedure, even the establishing of a large per- 
manent postauricular opening, can be expected to bring 
about a permanent cure of chronic otorrhea due to the 
presence of cholesteatoma. Reinhard states that mem- 
branes still continued to exfoliate in the cases that he had 



OPERATIONS UPON THE MIDDLE EAR 433 

operated upon by establishing a large permanent postauric- 
ular opening into the antrum, and required removal to pre- 
vent the recurrence of suppuration ; " in some more fre- 
quently, sometimes but once in three years." The same rule 
applies to all cases of chronic suppuration where the middle 
ear has become epidermized. Whether an operation has 
been performed or not, cholesteatomatous masses will form, 
and their removal from time to time is necessary in order to 
prevent a recurrence of the suppuration. 

Where the middle ear is dry, exfoliated epidermis will re- 
main for a considerable period within it without giving rise 
to suppuration. In i case the author had succeeded in 
bringing about a cessation of a tedious otorrhea after the 




Fig. 234. — Lateral surface of the median portion of the same specimen. A part of the 
auditory meatus has heen cut away and the specimen tilted toward the right in order to 
show the membrana tympani in the photograph, which is on a somewhat larger scale than 
Fig. 233: A, Aditus containing part of the cholesteatoma, which extends into and com- 
pletely fills the attic ; the tegmen of the aditus and antrum is extremely thin and discolored 
about a small perforation that extends from the antrum into the middle cranial fossa ; MH, 
malleus handle attached to the promontory throughout its entire length in such a manner 
that the portion of the atrium anterior to the malleus is the only part of the middle ear com- 
municating with the Eustachian tube. The membrana tympani is cicatricial and collapsed. 
There are two large perforations posterior to the malleus handle and one anterior. 

removal of the remains of the malleus and incus. One 
year afterward there were removed from his attic epidermal 
scales, some of which were stained with pyoktanin, which 
had been used in the treatment of his ear the year before. 
Relapses after simple mastoid operations in cases of 
chronic otorrhea were notoriously frequent, and in all such 
cases the necessity for a secondary operation is the accu- 
mulation of cholesteatomatous masses within the middle 
ear. In some instances years may elapse before such 
masses cause marked aural symptoms, but finally suppura- 
tion occurs, and the mastoid antrum has to be reopened to 

28 



434 -DISEASES OE THE NOSE, THROAT, AND EAR 

permit the removal of material that fails to find a ready exit 
through the tympanum and the auditory canal. Therefore 
it is better in cases of mastoiditis occurring in the course of 
chronic suppuration to do a radical rather than a simple 
mastoid operation. 

In some instances nature does a Stacke operation as the 
result of necrosis of the lateral bony attic wall, or a large 
permanent postauricular opening may occur behind the 
auricle, leading directly into the antrum. In either case the 
middle ear becomes completely epidermized ; but suppura- 
tion tends to recur if epidermal scales are not removed 
from time to time. The advantage of such large openings, 
secured either by art or by nature, is that epidermal scales 
and other debris can be readily removed. 

Operation for the Removal of the Remains of the Drum-head, 
Malleus, and Incus in Suppurative Cases. — The operation is 
better done under cocain anesthesia by the transfusion 
method of Ballin (Formula i8) or a general anesthetic may 
be employed. However, when a large amount of the intra- 
tympanic mucous membrane is exposed as the result of 
disease, except in nervous patients, simply the appHcation 
of a lO per cent, solution of cocain yields fairly satisfactory 
anesthesia. 

If the incudostapedial articulation is intact and visible, it 
is well to begin the operation by severing the joint, to avoid 
possible injury to the stapes while removing the incus. If 
the membrana flaccida is intact, the sharp- pointed knife 
(Fig. 229, c) is thrust through it behind the short process, 
as close as possible to the margin of the annulus, and the 
incision continued backward and downward for a sufficient 
distance to completely sever the posterior attachments of 
the malleus. Without removing the knife from the wound 
its edge is turned in the opposite direction, its point is 
slightly withdrawn so as to ride over the malleus above the 
short process, and the anterior attachments of the malleus 
are rapidly severed. The neck of the malleus is seized with 
Sexton's foreign-body forceps and an effort made to dislodge 
the head of the malleus from the scute or shelf of bone on 
which it lies in the lateral portion of the attic, by gentle 
pressure inward and downward with the forceps. Should 



OPERATIONS UPON THE MIDDLE EAR 435 

gentle manipulation not succeed, it is probable that the 
malleus is held in position by adhesions to the tympanic 
walls. Any adhesions that can be reached should be sev- 
ered by means of angular knives (Fig. 229, / and g). By 
means of one of these knives or the incus-hook (Fig. 229, U) 
traction directly outward should be made upon the tip of 
the malleus handle until the head of the bonelet is dislodged 
inward. If now the bonelet be seized in the neighborhood 
of the short process with the foreign-body forceps it will 
readily be removed by traction — at first inward and down- 
ward and then outward. 

The malleus when withdrawn from the ear should be in- 
spected to determine whether or not the incus is adherent 
to it. In not a few instances the bonelets will be found 
firmly bound together by bony ankylosis or strong fibrous 
bands, so that both bonelets will be removed together. If 
this does not occur, and the presence of the incus has been 
determined previous to the operation by the use of an Allen 
probe the tip of which has been bent upward and guarded 
by a few fibers of cotton wrapped about it, a diligent search 
should be made for the incus by means of incus-hooks 
(Fig. 229, k and /). The incus will probably be found be- 
hind the annulus, dislocated downward and outward as the 
result of the withdrawal of the malleus. The tip of its long 
process will probably be found close behind the annulus 
posteriorly and somewhat below the middle of the tym- 
panum. If the incus-hook (Fig. 229, k for the left ear and 
/ for the right ear) be introduced into the lower part of the 
tympanum, with its concave surface upward and the tip of 
the hook behind the annulus, by lifting the hook slightly 
upward and at the same time rotating it the long process of 
the incus will probably be pushed anteriorly into view from 
behind the annulus. In executing this maneuver it is 
necessary that the tip of the hook be held somewhat closely 
in contact with the median surface of the annulus. The 
rotation of the hook may have to be repeated several times 
before the incus-shank is brought into view. The ossicle 
will probably be found lying somewhat lower down in the 
tympanum than would naturally be expected, but if careful 
manipulation of the hook fails to locate it in this region, the 



436 DISEASES OF THE NOSE, THROAT, AND EAR 

ossicle should be searched for higher up, and if necessary 
the other hook may be inserted with its concavity down- 
ward and its tip behind the scute, and rotated in such a 
manner as to dislocate the ossicle downward. This man- 
euver should be executed with great care and gentleness, as 
there is danger of pushing the ossicle backward into the 
antrum. After the incus is brought into view it should be 
seized with the forceps manipulated in such a manner as to 
free it from the annulus and withdrawn. 

It should be borne in mind that the first portion of the 
ossicle destroyed by caries is the long process, and that it 
sometimes requires but a short period of suppuration to 
cause the entire destruction of this ossicle. Too prolonged 
search for the incus after the removal of the malleus is not 
advisable, unless it is certain from previous examinations 
that the incus is certainly present. 

After the withdrawal of the incus, the edge of the annulus 
and the tympanic vault should be carefully searched by 
means of a* cotton-tipped probe for exposed bone or areas 
of granulations. If such spots be found, they should care- 
fully be cureted by means of a bent curet (Fig. 229, h or i). 
The success of the operation in bringing about a cessation 
of persistent or recurrent suppuration will often depend 
upon the thoroughness and care with which this is done. 
Any remaining portions of the membrana should also be 
removed with the probe-pointed knife or with a curet. 

The remains of the incus, even when firmly bound down 
by adhesions, polypi, and cholesteatomatous material, may 
readily be removed by means of Allport's ingenious curet 
forceps (Fig. 235). The closed blades of the instrument are 
introduced into the attic, then cautiously opened, and the 
incus or a polypus searched for. When something is felt 
to be within the grasp of the little curets in which the blades 
terminate the instrument is withdrawn. This maneuver is 
repeated until the attic is completely emptied of all morbid 
material. Sometimes comparatively large polypi — whose 
presence in the attic is unsuspected because they cannot be 
seen — are removed in this manner, and the incus, although 
unseen, can usually be extracted with comparative ease. 
Care should be used when working in the region of the 



OPERATIONS UPON TJIE MIDDLE EAR 437 

oval window not to inadvertently i^rasp and remove the 
stapes. 

In operating upon the anterior or inferior portion of the 
tympanum the position of the carotid artery and the bulb 
of the jugular vein should be borne in mind (Figs. 236, 243, 
259). Ordinarily the jugular vein is covered by bone of 
sufficient thickness to prevent injury to the vessel, but 
sometimes this bone is lacking and the vein lies just below 
the tympanic mucous membrane. Several cases of injury 
to the jugular vein during intratympanic operations have 
occurred, but without fatal results. Although no cases of 
injury to the carotid artery during operations upon the mid- 
dle ear are known, yet the artery lies dangerously near 
anteriorly, and it is well to use a probe-pointed knife when 




Fig. 235 — Allport's middle-ear forceps. 

operating in this locality. Hemorrhage from this portion 
of the artery as the result of necrosis has almost invariably 
sooner or later terminated fatally, even after ligation of the 
internal carotid artery in the neck. 

After the removal of the malleus and incus, if it be deemed 
necessary in order to gain better access to the attic for after- 
treatment, the lateral wall of the attic may be removed by 
means of the curet (Fig. 256). This procedure is some- 
what more difficult than the Stacke operation (see p. 438), 
but can be done without displacing the auricle (a source 
of dread to many patients) and yields very satisfactory 
results. 

The after-treatment of the operation for the removal of 
the remains of the drum-head, malleus, and incus in suppu- 



438 DISEASES OE THE NOSE, THROAT, AND EAR 

rative cases is similar to that already described after opera- 
tion in catarrhal cases. 




Fig. 236. — Vertical frontal section through the middle of the external meatus : A, Ante- 
rior. P, posterior portion of the specimen ; S, scute or external bony wall of attic ; C", carotid 
artery; J, internal jugular vein. The carotid is separated from the anterior median wall 
of the tympanum by an extremely thin septum of bone, which in numerous instances is 
entirely lacking, so that the vessel might be wounded by the knife of a heedless operator 
during an intratympanic operation. The bulb of the jugular vein is separated from the 
cavity of the tympanum by the mucous membrane and a thin septum of bone that is some- 
times lacking. The bulb of the jugular vein has been wounded during the operation of 
paracentesis. In the specimen the drum-head, malleus, and incus have disappeared as the 
result, probably, of chronic suppuration. (From a photograph of a dried preparation in the 
author's collection.) 



Stacke's Operation. — The indications for the operation are 
caries of the walls of the tympanic cavity and ossicula; 
excessive growth of granulations in the tympanic cavity, 



OPERATIONS UPON THE MIDDLE EAR 



439 



with cholestcatomatOLis formation in the attic ; if suppuration 
continues for a \ov\g time in spite of careful after-treatment 
following a mastoid operation according to Schwartze's 
method, or if dangerous symptoms arise during the after- 
treatment. 

TccJiuic. — An incision is made to the bone, from the tip of 
the mastoid around the attachment of the auricle to a point 




Fig. 237. — Adult temporal bone, with the upper and part of the posterior wall of the 
meatus chiseled away so as to form one large cavity of the meatus, tympanum, and antrum : 
A, Hard ridge of bone surrounding the Fallopian canal. Within the tympanum the oval 
and round windows are plainly shown. It should be borne in mind that the facial nerve 
arches backward above the oval window and then descends vertically (I*'igs. 173, 176, 239, 
240). The inner end of the ridge of bone between the auditory canal and mastoid near A 
is, therefore, not far distant from this nerve, and considerable caution should be used in 
smoothing down this portion of the ridge, the outer portion of which can be removed quickly 
with rongeur forceps without pain or difficulty. In a complete Kiister operation healing 
will be facilitated and a better final result obtained by removing not only the ridge between 
the canal and the operative cavity in the mastoid but also the overhanging edge of bone 
about this cavity, both above and behind, to render the operative cavity as flat, smooth, 
and shallow as possible. The root of the z^'gomatic process and the tip of the mastoid 
contain cells, and in most instances it is desirable to open these cells thoroughly. The ridge 
between the canal and the operative cavity and overhanging edges have been allowed to 
remain in Figs. 237 and 238 in order to better show the topography. (From a photograph 
of a preparation in the author's collection.) 



above the tragus. The periosteum is then pushed forward 
with the anterior flap until the superior and posterior mar- 
gins of the osseous canal are brought clearly into view. 
The cartilaginous canal and as much of the periosteum as 
possible are now separated from the bony canal by means 
of a small elevator. An incision is made through the loos- 
ened tissues as close to the drum-head as possible, and by 



440 DISEASES OE THE NOSE, THROAT, AND EAR 

traction forward upon the auricle the funnel-shaped mass is 
pulled out of the bony canal, exposing the tympanic struc- 
tures clearly to view. By means of the mallet, gouge, and 
curet the upper posterior wall of the inner meatus is re- 
moved, layer by layer, until the attic is fully exposed to 
view. If the malleus and incus are present they should 
then be removed with the forceps, care being exercised at 
every stage of the operation to protect the stapes. The 
chiseling should be continued until the curet no longer 




Fig. 238. — Kiister's operation. The auricle is turned forward, the cartilaginous meatus 
detached, and the bony wall of the meatus chiseled away as in Fig. 237. The malleus and 
incus still rernain in position, but are somewhat dimly seen in the figure. (From a photo- 
graph of a dried preparation in the author's collection.) 

catches upon an overhanging ledge of bone while being 
drawn from the meatus. If it is thought desirable to open 
the antrum, the chiseling should be continued posteriorly 
until this cavity is freely exposed to view (Figs. 237, 238). 
At all stages of the operation the curet (Fig. 256) will be 
found a most valuable aid to the removal of the sharp edge 
of bone overhanging the canal. Its curved tip should be 
cautiously introduced into the tympanum beneath the over- 
hanging bone, which is somewhat rapidly cut away, not by 



OPERATIONS UPON THE MIDDLE EAR 44 1 

drawing the instrument outward, but by rotatin^^ it in such 
a manner that the bone is cut alternately by the sharp ante- 
rior and posterior edges of the cup, the curved tip of the 
curet in the meanwhile preventing the instrument from be- 
coming displaced. In order to afford a firm grasp upon the 
instrument while executing this maneuver, the handle of 
the instrument between the cups is made very broad and 
roughened. 

After all affected parts have been removed, the attic and, 
if necessary, the antrum fully exposed, the soft parts are 
replaced, the external incision sutured, and the auditory 
canal lightly packed with gauze. 

In some instances, where the attic is known to be occu- 
pied by pulpy granulations and cholesteatomatous masses, 
it is well to perform Stacke's operation after opening the 
mastoid antrum through the cortex of the mastoid accord- 
ing to Schwartze's method, subsequently to be described. 

Kiister, after opening the mastoid antrum by Schwartze's 
method, chisels away the intervening bone between the 
meatus and the artificial opening through the cortex of the 
mastoid. The disadvantage of this method is that it is some- 
what slow and tedious, and that the removal of the "scute" 
or outer wall of the attic, being left until the last, is apt to be 
slighted and neglected, although the most important part 
of the operation, so far as accomplishing the result of affect- 
ing ultimate cessation of chronic suppuration is concerned. 

Most operators prefer to use for opening the mastoid 
antrum, either by Schwartze's or Stacke's method, a chisel 
and mallet. Whiting's set of chisels and gouges (Fig. 257) 
being ordinarily employed for this purpose. 

When chiseling away the posterior superior wall of the 
meatus and opening the attic, the topographic relation of 
the posterior wall of the meatus to the descending portion 
of the facial nerve should be borne in mind. The aquae- 
ductus Fallopii does not extend downward and outward, as 
stated in some text-books upon anatomy, but directly down- 
ward (Figs. 239, 240). Indeed, if two probes be inserted 
into the facial canals through the stylomastoid foramina of 
any skull, it will be found that the probes are parallel, or in 
some instances incline somewhat toward each other. Al- 



442 DJSEASES OF THE NOSE, THROAT, AND EAR 




Fig. 239. — Vertical frontal section through the skull, anterior portion of the specimen 
seen from behind. The saw has passed through the spina on the right side and laid open 
the aquaeductus Fallopii through its entire vertical portion, showing the facial nerve, under 
which a pin has been passed. It should be observed that the nerve lies nearly vertical in 
this part of its course, while above and fxternal to it is an opening into the most external 
portion of the horizontal semicircular canal. The anterior part of the antrum, A, has been 
opened, and also the vestibule, V, and the superior semicircular canal. On the left side the 
saw has passed through the posterior portion of the external and internal meatus, removing 
the posterior edge of the drum-head and the incus. The stapes still retains its position in 
the oval window. Below the tympanum is the bulb of the jugular vein. In comparing 
Fig. 23P with Fig. 240, note that the saw has passed slightly more anteriorly through the 
left ear of the specimen. (From a dried preparation in the author's collection.) 

though the course of the descending portion of the facial 
nerve is vertical, yet, because of the upward and outward 
inclination of the drum-head, the facial nerve approaches 
the annulus to within i or 2 minimeters posteriorly, on a 



OPERATIONS UPON THE MIDDLE EAR 



443 



level with the center of the meatus ; 
the posterior wall be removed, it wil 



hence, if the whole of 
[ be impossible to avoid 




Fig. 240. — Vertical section through the skull, posterior portion of the same specimen 
as Fig. 239. On the left side the saw has passed just anterior to the aquacductus Fallopii, 
and a pin has been passed under the facial nerve, N. at its exit from the stylomastoid fora- 
men. Above is seen an opening made into the commencement of the vertical portion of 
the facial canal. Still higher up is a portion of the horizontal semicircular canal (//) laid 
open and occupying a position somewhat lateral to the facial nerve and median to the 
aditus {A"), On the right side the section has passed through the anterior part of the 
antrum and is posterior to the facial canal, and has opened the horizontal semicircular 
canal at its most external part. (F'rom a dried preparation in the author's collection.) 

injuring the facial nerve. The Fallopian canal is contained 
in a hard mass of bone (Figs. 240, 242), and hence is pro- 
tected to a certain extent from injury if the operator is skil- 



444 DISEASES OF THE NOSE, THROAT, AND EAR 

ful and careful. The student should study the topographic 
relation of the structures involved in operations upon the 
middle ear by preparing a large number of frontal, sagittal, 
and horizontal sections of the ear. Such sections should 
be made, not through a separated temporal bone, but while 
the bone is still in position in the skull. Injected heads, 
sawn in half through the sagittal suture and mummified by 
exposure upon the roof of a house for a few months, are 
very suitable for making such sections. After the sections 




Fig. 241. — Vertical sagittal section through the tympanum ; median aspect of the lat- 
eral portion of the specimen. The lower part of the membrana tympani is cut away by the 
saw, and above the drum-head inclines outward at an angle of 140 degrees with the upper 
wall of the meatus. The malleus handle and the malleo-incudal articulation, as well as the 
descending process of the incus, are visible. The section passes through the canal for the 
tensor tympani muscle, so that the trochlea and tendon are shown. Above the tympanum 
portions of each of the semicircular canals are visible. (From a dried preparation in the 
author's cabinet.) 



are made the parts should be freed from fat by repeated 
soakings in gasoline or benzine. By careful attention to this 
detail the specimens may be rendered almost devoid of 
smell, as the foul odor originates principally in the fat of the 
tissues. 

The specimens may be further cleansed and bleached by 
placing them in the sun and spraying them from time to 
time with an atomizer containing peroxid of hydrogen ren- 
dered slightly alkaline by the addition of liquor potassae. 



OPERATIONS UPON THE MIDDLE EAR 



445 



After subsequent drying the soft parts should be preserved 
by applying to them several coats of bleached shellac var- 
nish, which may be made to assume any color required to 
render the structure more natural in appearance by the ad- 
dition of one of the aniline dyes. Each coat of varnish is 
allowed to soak well into the soft tissues in order to pre- 
serve them. However, specimens of a large section of the 
head prepared in this manner are rather too realistic to show 
indiscriminately to office patients, as by the skilful use of 




Fig. 242. — Posterior surface of the portion of the ear removed by the two vertical frontal 
saw-cuts seen in Fig. 241. The external bony meatus has been laid open only at its most 
external portion. Above, the saw has passed through the aditus and posterior to the facial 
canal : A, Aditus, with its bony roof partly removed ; //, horizontal semicircular canal ; 
I\I, meatus ; N, facial nerve. 



the aniline dyes they are made to look as if still bleeding 
and freshly severed from the body. Therefore if it is found 
convenient to have a few specimens like Fig. 95 or 236 
for example, to aid in the explanation to patients of a pro- 
posed operation, it is better to coat such specimens with 
aluminum or bronze paint. The most useful sections for 
purposes of study are a vertical, frontal section through the 
spina suprameatum (Figs. 242, 248). a vertical sagittal sec- 
tion through the floor of the tympan'jm (Fig. 241), a hori- 



44^ DISEASES OF THE NOSE, THROAT, AND EAR 

zontal section through the roof of the meatus (Fig. 243), 
and a section parallel to the inner wall of the tympanum 
(Figs. 172, 173). Besides making the sections through the 
middle ear, the student would do well to operate many 
times upon the cadaver before attempting any serious opera- 
tion involving the muddle ear of a patient. 




Fig. 243. — Horizontal section through the roof of the external meatus : /, Inferior por- 
tion ; S, superior portion of the specimen ; I\T, external auditory meatus ; T. tympanum ; 
M.A, mastoid antrum; A, carotid artery; L.S, lateral sinus; B, bulb of the jugular vein; 
N, facial nerve. In the lower half of the specimen is the handle and short process of the 
malleus, the saw having passed through the neck of the bonelet. The membrane slopes 
obliquely forward at an angle of 55 degrees with the axis of the meatus, and outward at an 
angle of 140 degrees with the roof of the meatus. The section passes through the oval 
window, so that the cavity of the vestibule (V), as well as the cochlea (C), is shown in the 
upper half of the specimen. Here also is to be seen the malleus head, the incus, the attic, 
and the mastoid antrum. The stapes has been removed by the saw. The bulb (5) of the 
jugular vein extends further upward than in most specimens. (Author's specimen.) 



Mastoiditis. — Tlie External and Middle Eai' of a Newborn 
Child.— Kx. birth the external meatus is essentially a closed 
canal. The drum-head lies nearly in the same plane with 
the upper wall of the meatus (Fig. 244), and forms such an 
extremely acute angle with the lower wall that the upper 
and lower walls are practically in contact except for the 
vernix caseosa (greasy paste), which, covering the entire 
body of the child at birth, also extends into the auditory 



OPERATIONS UPON Till': MID DTK PAR 



447 



canal, completely blockini^ it up so that no air can enter. 
The drum-head is covered by extremely thick epidermis, 
while the cavity of the tymp.inum is usually completely 
filled with its own mucous membrane, which, enormously 
hypertrophied at all parts of the tympanum, is thickest 
upon the inner wall, where it is markedly hyperemic and 
jelly-like in appearance, in marked contrast to tliat of adult 
life, which upon the promontory is thin and nearly blood- 
less in appearance. 




MN 



Fig. 244. — Vertical frontal section through the external auditory canals of a fetus still- 
born at the end of the seventh month, anterior portion of the head. The external auditory 
canals slope somewhat downward and the membrana tympani are nearly horizontal. 'I'he 
lower wall of each canal is in contact with the upper except for the presence of a small 
quantity of the same cheesy material (7'eynix casros(i) that covered the rest of the skin of 
the fetus. The tympanum is completely filled by the ossicles and its own mucous mem- 
brane, which is much thicker than that of the adult. The malleus is in position in the right 
ear, but has been removed by the saw from the left : B, Brain ; AT.H, head of the malleus ; 
C, cochlea of the left ear. (From a specimen in the author's collection.) 



Hence, the offspring of the human race is, like that of 
many of the lower animals, born into the world almost 
completely deaf. Almost from birth the eyes of an infant 
follow the movements of individuals about the room, but it 
is not until the eighth or tenth day after birth that an in- 
fant shows any evidence of hearing the sound of a tuning- 
fork held close to its ear. At birth or soon afterward the 
tympanum becomes a cavity containing air. The thick epi- 



448 DISEASES OF THE NOSE, THROAT, AND EAR 

dermis of the outer layer of the drum-head is exfoHated 
and the mucous cushions within the tympanum disappear. 



sp 




Fig. 245. — Left half of the skull of a stillborn infant, showing the inferior surface of the 
petrous bone, the annulus tympanicus, the ossicles, the tympanum, and the mastoid process. 
The ossicles, the tympanum, and the mastoid antrum are nearly as large as those of an 
adult : M, ]\Iastoid process. The end of the line is at the stylomastoid foramen. Hence 
at birth the facial nerve emerges not as in the adult on the inferior, but on the lateral, sur- 
face of the temporal bone. Therefore it readily maj- be wounded during a mastoid opera- 
tion by a careless operator or. injured by too tightly packing or bandaging the mastoid 
wound ; S.P, short process of the malleus ; P. T, posterior tubercle of the annulus tympan- 
icus. (From a specimen in the author's collection.) 




S.P.\ 



Fig. 246.— Same specimen as Fig. 245, but with the mastoid antrum exposed, showing its 
normal position at birth immediately above the posterior tubercle of the annulus. 

The osseous canal of the adult is represented in infants 
by the amuihts tympaiiiciis or processus anditorins (Figs. 
245, 247), one of the three separate bones comprising the 



OPERATIONS UPON THE MIDDLE EAR 



449 



temporal, and forming by gradual development the vaginal 
process of the auditory meatus of the adult. The rest of 
the canal is composed largely of embryonic tissues covered 
by skin, and measures from the tragus to the umbo usually 
about 30 mm., while that of the adult measures from 31 to 
35 mm. between the same structures. Because of the nearly 
horizontal position of the drum-head, Shrapnell's membrane 
(Fig. 172) lies so near the orifice of the canal that when 

■Portion, ^^^ 




Fig. 247. — The temporal bone of a newborn child separated into its three component 
parts : the squamous and petrous portions and the annulus tympanicus or processus 
auditorius (Gray). 



greatly swollen it almost protrudes, resembling a polypus 
somewhat in appearance ; indeed, it has been mistaken for 
a polypus and removed, together with the malleus and incus. 
To examine the druin-liead of young cliildrcn it is neces- 
sary to draw the lobule downward in order to detach the 
lower from the upper wall of the meatus. The ossicles, 
tympanum, and mastoid antrum are nearly as large as those 
of an adult, but are superficially situated, and in opening a 
mastoid abscess in an infant, therefore, it is not unusual for 
29 



450 DISEASES OF THE NOSE, THROAT, AND EAR 

the probe to pass through the antrum into the attic for a 
distance of nearly i inch. The mastoid antrum of young 
infants is situated immediately above the posterior tubercle 
of the annulus (Fig. 245), and this elevation should be 
searched for as a landmark when operating upon the tem- 
poral bone of infants. It should also be borne in mind that 
the mastoid-squamous suture (Fig. 245) is not ossified at 
birth, and frequently presents large dehiscences during 
childhood, so that when making the primary incision for a 




Fig. 248. — Vertical frontal section through the spina of a child eight years old : F, Ante- 
rior, B, posterior portion of the specimen; at, attic with tegmen removed; v, vestibule with 
horizontal and superior semicircular canals laid open; /.tympanum; _/', jugular vein ; f, 
aquseductus Fallopii ; «, mastoid antrum; //;/, internal meatus; i r, saw-cut through the 
center of the modiolus, at right angles to the tubotympanic axis, in order to lay open the 
cochlea. A section of this kind through the modiolus is commended to students as show- 
ing the topography of the anterior portion of the tympanum in relation to the articulation of 
the lower jaw and the carotid artery. (From a dry preparation in the author's collection.) 



mastoid operation upon a young child the point of the knife 
should not be pressed with force against the bone or it may 
enter one of these dehiscences and penetrate the cranial 
cavity. The incision should be made with due deliberation 
until the bone is exposed in the whole length of the incis- 
ion, and the periosteum pushed forward with great care and 
gentleness. It should be borne in mind also that at birth 
\h^ facial nerve emerges not on the inferior surface, but on 
the external (lateral) surface of the temporal bone, at a point 
close to the annulus and somewhat above its inferior border 



OPERATIONS UPON TIIK MIDDLE EAR 45 I 

(Fig. 245). Unnecessary curctini^ within tlie nicistoid an- 
trum and attic should also be avoided, as the petrosquamous 
suture, where the horizontal plate of the squamous portion 
of the temporal bone unites with the petrous portion to 
form the tegmen or roof of the tympanum and antrum, 
remains open for some time after birth, and a process from 
the dura not infrequently extends downward to unite with 
the mucous membrane of the middle ear. 

The Adult Mastoid Process. — At birth the mastoid proc- 
ess consists of a small flattened tuberosity containing but 
one cell, the mastoid antrum. At the age of eight years 
the child's mastoid generally contains numerous other pneu- 
matic spaces radiating from the antrum, and its topographic 




Fig. 249. — Large-celled pneumatic processes; the tip of the one to the left is diploetic. 
(Author's specimens.) 

relations are well shown in Fig. 245. At puberty the mas- 
toid has become a distinct prominence, conic in shape, with 
its apex downward. It may or may not contain pneumatic 
cells in addition to the antrum. 

Types of Mastoid Stnictiire. — There are four distinct 
types of mastoid structure : 

I. The pneumatic, in which the w^hole mastoid process is 
composed of pneumatic spaces communicating with each 
other and with the antrum, and lined with a continuation 
of the mucous membrane of the middle ear. The pneu- 
matic spaces may be large (Fig. 249) or small (Fig. 250). 
If the pneumatic spaces are small, one comparatively large 
cell is generally found at the mastoid tip. 



452 DISEASES OF THE lYOSE, THROAT, AND EAR 

2. The diploetic, the entire bone containing no air-spaces, 
but composed of diploetic tissue. 

3. The pneumodiploetic, in which pneumatic spaces and 
diploetic tissue are both found (Fig. 249). 

4. The sclerosed, in which the entire bone is composed 
of compact bone often as hard as a tooth (Fig. 251). 

Pathologic Importance of Types. — Pathologically and sur- 
gically the structure of the mastoid process is of the utmost 
importance. In the pneumatic type of mastoid with large 
cells, pus from the antrum readily finds its way to the lateral 
surface, but in the diploetic, and more especially in the 




Fig. 250. — Frontal section through the spina of a mastoid process consisting almost 
entirel}- of small pneimiatic cells : F, Anterior, B, posterior portion of the specimen ; A, 
antrum; C, large cell at the tip of the process : the semicircular canals and the aquaeductus 
Fallopii have been laid open after the section was made. (Author's specimen.) 

sclerosed type, there is greater danger of pus burrowing its 
way into the cranial cavity. The difficulties of the mastoid 
operation are also greatly increased by the compactness and 
hardness of the bone. Where a large cell is present at the 
mastoid tip with a thin median wall, pus is more Hkely to 
find its way into the digastric fossae than to penetrate the 
thicker external cortex. 

Etiology. — Primary inflammation of the mastoid never 
occurs except as the result of syphilis, tuberculosis, or 
traumatism, especially in individuals with chronic suppura- 
tion of the tympanum and attic. The symptoms are those 
of acute periostitis, pain, heat, and swelHng behind the ear. 



OPERATIONS UPON THE MIDDLE EAR 



453 



Within a few days the periostitis subsides or tlic deeper 
structures become involved. In such cases should caries 
occur, the abscess-cavity does not usually communicate 
with the mastoid. antrum, but is generally superficially situ- 
ated beneath the cortex of the bone. However, the dis- 
ease in almost every instance is the result of an exteitsion, 
by continuity of structure, of inflammation from the tym- 
panum. Politzer states that in every post mortem that he 
made of chronic suppuration of the middle ear the mastoid 
cells were diseased. Mastoiditis, then, 
is generally the sequence of acute in- 
flammation of the tympanum or of 
chronic suppuration of the middle ear. 
In rare instances suppurative inflamma- 
tion of the deeper portion of the audi- 
tory canal may extend under the peri- 
osteum until pus appears upon the 
external surface of the mastoid beneath 
the periosteum (Fig. 252); or infection 
may be transmitted by means of the 
veins which traverse canals passing 
from the meatus into the mastoid cells. 
Pathology. — The most acute cases, 
starting in an inflammation of the mu- 
cous membrane of the middle ear and 
mastoid antrum, and extending to that 
lining the mastoid cells, run a most 
rapid course, but a few days elapsing 
between the onset of the disease and 
the operative opening of the mastoid 
necessary for the removal of pus and 

necrotic bone. In such cases the pain is persistent or only 
temporarily relieved by applications of ice to the mastoid 
or the administration of opiates. The patient's face as- 
sumes the expression of abject woe. He eats little and 
sleeps less. The infection is usually streptococci, which 
when present indicate rapid caries and the necessity for an 
early operation. The middle-ear symptoms, however, may 
have subsided and for weeks all signs of mastoiditis have 
disappeared, except perhaps slight tenderness on deep press- 




FiG. 251. — Vertical sagittal 
section through a sclerosed 
mastoid process, the cellular 
structure of which, with the 
exception of an exceedingly 
small antrum, has been en- 
tirely replaced by dense ebur- 
nated bone (from a specimen 
in the author's cabinet). 



454 DISEASES OF THE NOSE, THROAT, AND EAR 

ure over the bone, with occasional slight shooting pain 
through it, when a fluctuating swelHng appears over the 
mastoid bone, the digastric fossae, or in the deep tissues of 
the neck, indicating that spontaneous perforation of the 
cortex of the mastoid bone has occurred and released the 
contained pus. 

The changes that occur in slowly progressive inflamma- 
tion of the mastoid cells are of two kinds. Sometimes a 
limited caries is produced, the surrounding tissues being 




Fig. 252. — Periostitis and caries of the petrous portion of the temporal bone after otitis 
media, in a boy three years of age (Fruhwald). 

thickened and consolidated to the extent of entirely oblit- 
erating the pneumatic spaces. Where the active inflamma- 
tion has subsided without suppuration, hyperostosis, or con- 
solidation of the mastoid, may occur without necrosis or 
caries. 

In most chronic cases the mastoid antrum becomes filled 
with cholesteatomatous masses, thus isolating the mastoid 
cells from the tympanic cavity. Active mastoid complica- 
tions during chronic suppuration of the middle ear fre- 
quently manifest themselves during an acute exacerbation 
of the middle-ear disease, with the result of producing an 
acute inflammation of a limited area of bone in the center 
of a sclerosed mastoid. 

Caries or necrosis of the mastoid may extend inward and 



OPERATIONS UPON THE MIDDLE EAR 455 

involve the lateral sinus, producini^ phlebitis, thrombosis, 
emboli, and their consequences. The middle fossa of the 
skull may also be penetrated and an abscess produced be- 
neath the dura mater, a local pachymenin^^itis preventing 
further extension of the disease ; or meningitis, both at the 
base and convexity of the brain, or brain-abscess may 
occur. 

Symptoms. — In acute cases the first symptom is intense 
pain, involving the mastoid and often the whole side of the 
head. There are tenderness on pressure over the mastoid, 
fever, and in most cases swelling and congestion of the 
upper posterior part of the meatus. In the more chronic 
form of the disease the patient is sometimes remarkably 
free from pain, almost the first symptom to which the sur- 
geon's attention is called being congestion of Shrapnell's 
membrane, with swelling at the upper posterior part of the 
meatus, over the mastoid, or of the neck below the ear. 
Especially in children, the external cortex of the mastoid 
may be penetrated early in the disease and the pus find its 
way underneath the periosteum. Under such circum- 
stances the whole auricle, when seen from the rear, appears 
as if pushed out from the side of the head (Fig, 252). 

A symptom of considerable diagnostic importance is sud- 
den cessation of discliargc from the meatus in the course of 
an acute otorrhea. It is probably caused by lack of suffi- 
cient drainap'e from the attic and antrum. If the dischar""e 

... 
is not re-established within a few days, mastoid symptoms 

requiring operative interference generally manifest them- 
selves. 

In cases requiring operation the temperature is not a very 
reliable guide. In some cases it may be very little if any 
above the normal. Pain on pressure over the antrum or at 
the mastoid tip may disappear. However, when in con- 
junction with tenderness on pressure over the antrum, 
which has been present for some days, there is sw^elling of 
the posterior wall of the meatus close up to the drum-head, 
so that a portion of Shrapnell's membrane is hidden, an 
operation should not longer be delayed, as such cases rarely 
or never recover without. In making pressure over the 
antrum the observer should insert his finger at a level with 



456 DISEASES OF THE NOSE, THROAT, AND EAR 

the superior border of the meatus into the angle made by 
the junction of the auricle with the mastoid and press upon 
the bone in a direction backward and inward, being careful 
to move the auricle as little as possible, so as not to mis- 
take the pain commonly caused in acute suppuration of the 
middle ear by movements of the auricle for bone tender- 
ness over the antrum. 

A small lymphatic gland is found upon the surface of the 
mastoid about \ inch posterior to the meatus. Tenderness 
of this gland should not be mistaken for the bone tender- 
ness of mastoiditis. Should this gland become infected 
and break down as the result of furunculosis of the canal or 
other causes, the pus will be beneath the skin and not 
beneath the periosteum, and consequently the auricle will 
not, when seen from the rear, appear pushed ■ out from the 
side of the head (Fig. 252). Such superficial abscesses 
simply require opening and not a mastoid operation. 

Persistent tenderness of the mastoid tip and swelling of 
the tissues of the neck behind and below the mastoid indi- 
cate the presence of pus in the digastric fossae as the result 
of suppuration of the large cell at the tip of the mastoid. 
Usually the median bony wall of this cell is thinner than 
the external cortex and more readily breaks down. In 
such cases the entire tip of the mastoid should be removed 
at the mastoid operation and the abscess-cavity in the 
tissues of the neck laid freely open. 

It is often difficult to make an early diagnosis of com- 
mencing otic meningitis. The chief symptom at the begin- 
ning of brain complications is usually lieadache, which, at 
first intermittent, soon becomes constant and increases in 
severity. Accompanying the headache there are restless- 
ness, insomnia, occasional vomiting, and dulness of the intel- 
lect. If the eye be examined with the ophthalmoscope 
commencing optic neuritis will be discovered. In children 
coma frequently occurs. Dilatation of the pupil, paralysis 
of the accommodation, strabismus, ptosis, or paralysis of 
other muscles of the body may sometimes be present as the 
result of brain- abscess. The symptoms of phlebitis of the 
lateral sinus with the formation of a septic clot are chills, 
followed by high temperature, the characteristic temperature- 



OPERATIONS UPON THE MIDDLE EAR 457 

chart of septicemia. The circulation becomes checked as 
the result of the formation of a thrombus, which may in 
rare cases extend downward and backward to the torcular 
Herophili or into the jugular vein, where it may be felt as a 
hard cord, or into the mastoid vein, producing edema and 
inflammation of the posterior portion of the neck. 

Treatment. — When there is congestion of the posterior 
portion of Shrapnell's membrane and swelling of the neigh- 
boring tissues of the meatus a free incision through Shrap- 
nell's membrane and the swollen tissue will sometimes abort 
the attack. The mastoid process should be thickly covered 
with an ointment of 20 per cent, ichthyol in lanolin. The 
parts should then be covered with waxed paper and band- 
aged in order to prevent soiling the patient's clothing or 
bed-linen. 

Pain is best combated by the application of dry heat by 
means of a hot-water bag. If absolutely necessary an ano- 
dyne should be administered. Pain often can be relieved 
entirely for days by the application of cold to the mastoid 
process, either in the form of an ice-bag or Leiter's coil. 
However, this method is becoming less popular, as cold does 
not control the suppurative process, but simply masks its 
symptoms. The application of heat is the better treatment. 

Painting the mastoid process with iodin or cantharidal 
collodion renders the skin so sore that it is difficult to deter- 
mine whether tenderness on pressure is the result of the 
counter-irritant or inflammation of the bone. Although a 
favorite method of treatment with the aurists of half a cen- 
tury ago, it is doubtful if counter-irritation over the mastoid 
ever accomplished an appreciable amount of good. The 
writer has been called in consultation to see 2 cases of ery- 
sipelas apparently resulting from the application of canthar- 
idal collodion over the mastoid. One of these cases, an old 
man with advanced chronic Bright's disease, proved fatal. 

If, notwithstanding the application of ichthyol over the 
mastoid, dry heat, and the systematic treatment of the tym- 
panic suppuration, the tenderness over the mastoid is not 
relieved, and pain, sleeplessness, and loss of appetite in- 
crease, it is necessary to operate. 

The prognosis in uncomplicated mastoiditis is not un- 



458 DISEASES OF THE NOSE, THROAT, AND. EAR 

favorable. The major portion of cases recover with or 
without operation. The mastoid tenderness occurring in a 
large proportion of cases of acute suppuration of the mid- 
dle ear within a few days of the onset of the disease com- 
monly disappears within a short time as the result of treat- 
ment. The more severe forms of the disease occurring 
later, providing there is no swelling of the tissues at the 
inner upper portion of the canal, most frequently recover 
without operation if properly treated, if the infection is not 
due to the presence of streptococci or the result of la grippe. 
The prognosis in scarlatina, tuberculosis, diphtheria, etc., is, 
of course, more uncertain, wdth or without operation. 

The Mastoid Operation. — History. — The operation of open- 
ing the mastoid cells was first proposed by Riolanus about 
1600. Fifty years later the performance of the operation 
was opposed by Sir Thomas Browne. Trephining the mas- 
toid for the removal of the products of inflammation was 
first done by Jean Louis Petit, a distinguished French sur- 
geon, who died in 1750. The Prussian military surgeon, 
Jasser, trephined the mastoid process in 1776. His earlier 
operations were done for the release of the products of in- 
flammation and were highly successful, but he and his suc- 
cessors soon lost sight of the true indications for the opera- 
tion, which became very popular and was frequently per- 
formed for the relief of deafness and tinnitus. Disastrous 
and even fatal results were somewhat numerous, and finally 
culminated in the death of Baron von Berger, physician to 
the king of Denmark. Berger had suffered for some time 
from noises in the ears and gradually increasing deafness 
without suppuration. Perforation of the mastoid cells and 
the injection of an astringent solution were soon followed 
by fever and delirium, which ended in death on the eleventh 
day. At the post mortem the mastoid was found to be 
almost rudimentary and the trephine had entered the brain. 
Death resulted from purulent meningitis. Because of the 
prostitution of this most useful operation, trephining the 
mastoid fell into disrepute, and for nearly a century was 
referred to in medical literature as one of the curiosities of 
surgery rather than a justifiable procedure. 

The status of the mastoid operation was re-established by 



OPERATIONS UPON THE MIDDLE EAR 459 

the writings of Forget, in 1849, and those of Follin and von 
Troeltsch, in 1859. To Schwartzc is due the credit of de- 
veloping the mastoid operation as [)crformcd at the present 
time. Schvvartze's first series of 100 cases, published in 
1883, gave a death-rate of 20 per cent., a mortality that has 
been greatly decreased as the result of performing the 
operation earlier in the history of the disease, before intra- 
cranial complications have had time to develop. 

Toynbee ^ says, " I have never performed this operation, 
but I should not scruple to do so in a case where the life 
of the patient was threatened." He describes a case where 
mastoiditis was cured by wearing a seton for two years at 
the back of the neck. Toynbee of London and Wilde of 
Dublin were practically the fathers of modern otology, and 
Toynbee's observations on the pathology of mastoiditis 
and its intracranial complications make interesting and in- 
structive reading even at the present day. As indicating 
the number of deaths from mastoiditis in Ireland, Wilde ^ 
states, that while compiling the causes of deaths under the 
census commission of 1 841, his attention was attracted to 
the number of cases where the cause of death returned 
was, " died of a pain in the ear" or " was suddenly struck 
with a pain in the ear." As an example of how mastoiditis 
was treated in 1840 and the disastrous results obtained in 
some cases, the following extract from the work of George 
Pilcher^ will prove interesting: 

" A young man, aged seventeen, complained of pain and im- 
mobility of the neck, frequent headache, and a fetid discharge 
from the left ear, which had continued several weeks. This 
discharge had been preceded by acute pain, it came on sud- 
denly, and had been very copious from its first appearance, 
with an offensive smell. He had been deaf in that ear for 
some months, but did not seek medical assistance until mat- 
ter flowed from it. The neck was then blistered, the ear 
S3n'inged, and medicines administered, by which the pain of 
the ear was relieved ; but the neck became more stiff and 
painful, so that at length he was unable to turn his head in 

^ Diseases of the Ear, 2d Amer. ed., 1865, p. 360. 

2 Pud.^ Amer. ed., 1853, p. 320. 

' Pilcher on the Ear, Amer. ed., 1S43, P- 239. 



460 DISEASES OF THE NOSE, THROAT, AND EAR 

the least I found the muscles on the left side rigid and 
every part of the neck exquisitely sensitive, but especially 
near the atlas, and the least jarring motion caused agony. 
Notwithstanding he represented his sufferings to be con- 
tinual and his nights very frequently dreadful, his appetite 
was good and his strength sufficient to enable him to pur- 
sue his employment as a compositor in a printing-office. 
His countenance, however, was extremely pallid and 
anxious ; pulse 90, and feeble. From these symptoms I in- 
ferred that he labored under otitis, which had probably been 
communicated to the bony structure of the internal ear and 
other parts in the base of the skull ; the prognosis was, 
therefore, unfavorable. Leeches, fomentations, mercurials, 
and gentle aperients produced intervals of relief The mal- 
ady, however, evidently continued to advance, and at length 
he could no longer support his head without the aid of his 
hands nor separate his teeth more than \ inch. He lived 
in continual terror of moving, and felt, he said, as if his neck 
were broken. Considerable distortion of the cervical ver- 
tebrae was now apparent ; the spinous process of the dentata 
projected much toward the right side, more than i inch 
. from the mesial line, and a slight crepitus could be felt 
upon passing the finger from the first to the second vertebra. 
On either side of the atlas there was an unusual fulness, but 
the central part appeared depressed and it yielded to gentle 
pressure, which often seemed to produce a flow of pus from 
the diseased ear. A burning pain came on in violent par- 
oxysms, extending, as he described it, all over the inside of 
his head; it was excited by the least motion, and while it 
lasted he raved like one laboring under phrenitis ; its dura- 
tion varied from half an hour to two or three hours. He be- 
came hectic and extremely emaciated ; obtained no sleep with- 
out narcotics, which often procured a night's complete rest 
A succession of blisters were applied, but without benefit. 
In this miserable manner he proceeded, with little vari- 
ation, for six weeks, when, while his nurse was attempting 
to assist him in raising his head to move his pillow, he sud- 
denly became paralyzed in every limb. His intellect re- 
mained perfectly clear and his pulse continued about 90 ; his 
respiration was not remarkably affected, but he passed a 



OPERATIONS UPON THE MIDDLE EAR 46 1 

motion without his knowledge. lie died calmly, about six 
hours after the occurrence of this perfect paralysis. 

^'Inspection of the Body. — On handling the neck, pus 
flowed abundantly from the ear. Upon removing the cal- 
varium we found the dura mater rather adherent and more 
fluid than usual in the arachnoid cavity. The brain appeared 
healthy except that it was somewhat injected. No other 
signs of disease existed within the skull, but pus poured 
from the spinal canal through the foramen magnum. When 
the muscles of the neck were dissected those of the left side 
were found degenerated and pervaded by veins of curdled 
pus. The atlas was tilted on one side and very movable. 
On detaching it from the occiput we discovered that portion 
of the mastoid process, including the digastric fossa, and 
that part of the occipital bone connected with the left con- 
dyle partially destroyed by caries. The left occipito-atlan- 
toid ligaments were reduced to a pulp and the glenoid sur- 
face was denuded of its cartilage and roughened. The pro- 
cessus dentatus was carious and its ligaments were obliter- 
ated. The theca connected with the first and second verte- 
brae was inflamed and surrounded by pus, and the medulla 
itself broken down and mixed with sanious matter. The 
ulcerative action had commenced in the articulating surfaces 
of the atlas and dentata ; and an opening existed between 
the oblique processes of the second and third vertebrae on 
the right side, which communicated with an abscess among 
the muscles, and opened by a small aperture into the upper 
and back part of the pharynx." 

Technic. — The instruments required for the convenient 
performance of the mastoid operation are scalpels, five or 
six hemostats, a pair of broad retractors, Allport's dilator 
(Fig. 258), bone-gnawing forceps (Fig. 254), bone-gouges, 
chisels (Fig. 257), a mallet, two bone-curets (Figs. 253, 256), 
a steel grooved director, and a silver probe. 

While the operation 0/ opening the mastoid is generally 
performed for liberating the contents of a septic cavity, it 
should be done under antiseptic precautions. The instru- 
ments should be sterilized by boihng them in a 2 per cent, 
soda solution and the hands of the operator and those of 
his assistants disinfected in the usual manner. The patient's 



462 DISEASES OF THE iVOSE, THROAT, AND EAR 

hair should be shaved off for a distance of about 2 inches 
above and behind the ear to be operated upon. The skin 
covering the field of operation should be disinfected in the 
usual manner and the auditory canal syringed with warm 
bichlorid solution. These preparations of the patient for 
operation are better made previous to giving the ether. If 
the patient's hair is long it should be covered by a towel 
wet in bichlorid solution or a rubber cap. 




Fig. 253. — McKernon's mastoid curet. 

If the drum-head has not been perforated during the 
course of the disease, it is best to preface the operation by 
an incision around the posterior periphery. 

An incision is made through the skin to the bone from 
the tip of the mastoid to a point above the helix. The in- 
cision should be as close to the insertion of the auricle as 




Fig. 254. — Hopkins' rongeur forceps. 



possible. In the case of children this incision should be 
made somewhat deliberately with the edge of the knife 
rather than its point, so that there will be no danger of 
thrusting the knife point deeply into a dehiscency of the 
bone. In the case of adults the tip of the mastoid should 
be located with the end of the index-finger of the left hand 
and the point of the knife thrust at once through skin and 
periosteum into the bone. Maintaining firm pressure with 



OPERATIONS UPON THE MIDDLE EAR 463 

the knife point against the bone, the incision is continued 
upward around the auricle to stop at a point just short of 
the temporal artery, the exact position of which has pre- 
viously been located with a finger-tip of the left hand. If 
the incision is made in this manner it will cut through the 
periosteum the entire length of the cut, and facilitate strip- 
ping the periosteum from the bone without tearing it. 

After the incision has been made several little spurting 
arteries will require clamping with hemostats by the opera- 
tor or his assistant, and if the parts are brawny and swollen 
there will probably be a somewhat profuse venous hemor- 
rhage from all parts of the wound. This can be controlled 
by the application of hot water or may be disregarded until 
the periosteum is separated from the bone, as it will cease 
after Allport's dilator has been applied. If the mastoid 
process is large it may be desirable to secure additional 




Fig. 255. — Randall's hand-gouge. 

space by making an incision about i inch in length at right 
angles to the original incision from the center of the audi- 
tory meatus toward the occipital protuberance. The pres- 
ence of this second incision not only secures additional 
space, but has the advantage that the two posterior trian- 
gular flaps fall away from the bone and do not require the 
use of a retractor to hold the wound open. 

The periosteum should be separated from the bone with 
every precaution to avoid tearing it. It peals off from the 
bone very readily except when the mastoid is rough, and 
especially at the tips of the mastoid, where the sternocleido- 
mastoid muscle is attached. 

Randall's hand-gouge (Fig. 255) makes a very good 
periosteum elevator. From the smoother portions of the 
mastoid the periosteum is very quickly and readily pushed 
and pried loose, but the tip of the bone requires some skill 
and patience, as the attachments of the muscle are tough 



464 DISEASES OF THE NOSE, THROAT, AND EAR 

and the surface of the bone rough and uneven. However, 
if the concave surface of the gouge is kept closely in con- 
tact with the bone and the edge of the chisel is sharp, it is 
possible to remove the periosteum even in this locality 
without tearing it. 

As soon as the periosteum has been separated from the 
bone AUport's dilator (Fig. 258) is inserted in the wound. 
As the instrument is opened by means of the thumb-screw 
the wound becomes widely dilated and the pressure on the 
soft parts is sufficient to cause all hemorrhage to cease. 
Two of these instruments should be used ; one at each ex- 
tremity of the wound. The blunt hooks of the instruments 
should be kept closely in contact with the bone, as the 
blades are opened in order to grasp all of the tissues effi- 
ciently. However, as previously mentioned, if an incision 
is made at right angles to the original incision, no dilator 
and probably not even a retractor will be required to ex- 
pose the entire surface of the mastoid during the operation. 



Fig. 256. — Gleason's double-end bone-curet with curved tip. 

When the surface of the mastoid has been uncovered by 
the separation of its periosteum, it should be inspected care- 
fully with a probe or grooved director for the presence of 
any sinus or soft spot leading through its cortex to an ab- 
scess-cavity. If such a sinus is found it should be explored 
with a probe passed in the direction of the antrum and the 
softened cortex of the mastoid carefully scraped away with 
a curet (Fig. 253). The curet should be used in such a 
manner as not to endanger the lateral sinus (Figs. 259, 260). 

When the sinus has been sufficiently enlarged it may be 
found that the entire mastoid is a cavity filled with pus and 
pulpy granulations, every trace of cellular structure having 
disappeared. This condition of affairs is most likely to 
occur in large-celled pneumatic mastoids. Under such cir- 
cumstances the bony overhanging edge of the external 
cortex of the mastoid should be clipped away with the 
forceps (Fig. 254) until the abscess-cavity is thoroughly ex- 



OPERATIONS UPON THE MIDDLE EAR 



465 



posed. The pulpy granulations and debris should then be 
scraped away with the curet until firm normal bone is en- 
countered. However, the curet should be used with gen- 
tleness and judgment in positions where the lateral sinus is 
likely to be encountered, so as not unnecessarily and unex- 
pectedly to expose or even wound this important vessel. 
The position of the mastoid antrum should also be located 
with a probe and when working toward it with the curet 




Fig, 257. — Whiting's mastoid chisels and gouges. 

the position of the aquaeductus Fallopii (Figs. 173, 237, 239) 
should be borne in mind, so as to avoid danger of cureting 
away a part of the facial nerve. 

The floor of the mastoid antrum lies just behind and below 
the spina suprameatum (Fig. 260), in a direction parallel to 
the bony meatus. If the operator is in doubt as to the di- 
rection of the bony meatus it is permissible to insert a probe 

30 



466 DISEASES OF THE NOSE, THROAT, AND EAR 

between the bony and membranous meatus so as to be ab- 
solutely sure as to the proper direction in which to continue 
the use of the curet or the chisel. Not infrequently after 
the abscess-cavity in the mastoid has been cleansed there 
will be found only a small opening into the antrum, if, in- 
deed, any exist large enough to permit the passage of a 
probe. The bone in this locality is sometimes soft enough 
to permit it being readily scraped away with the curet. 
Under some circumstances Randall's hand-gouge is a most 
useful instrument. The index-finger of the right hand 
should be held close to the cutting edge to prevent the in- 
strument slipping, then, by slightly rotating the instrument 
as its edge is pressed firmly against the bone, even the hardest 
bone may be partly bored, partly gouged out, until at length 
the antrum is reached. The operator can assure himself 




Fig. 258.— Allport's dilator. 

that it is certainly the antrum that has been opened by 
passing a probe forward and outward through it into the 
attic. Fluid syringed into the antrum should appear in the 
meatus unless the aditus or attic is filled with granulations 
or the drum-head is not perforated. Should this be the 
case they should be removed by means of a small curet 
(Fig. 229, a), being careful not to dislocate the incus dur- 
ing the procedure. However, should it prove impossible to 
syringe from the attic into the meatus, no especial harm 
need be apprehended, as the passage will be probably estab- 
lished within a short time. 

Formerly, when the main abscess-cavity had been thor- 
oughly cleansed and a free communication established be- 
tween the mastoid antrum and the external wound the 
operation was considered complete. The larger porportion 



OPERATIONS UPON THE MIDDLE EAR 467 

of cases operated on in this manner make an uneventful re- 
covery and the resulting scar or deformity is inconspicuous. 
However, there are often a few cellular spaces above the 
meatus and in the root of the zygomatic process, so that in 
cases where the operation results in the formation of a dis- 
charging sinus the fistula frequently leads to one of the 
cell-spaces that was not thoroughly opened at the time 




Fig. 259. — Horizontal section through a right temporal bone below the spina, showing 
an extreme anterior and superficial position of the sigmoid sulcus, thus bringing the lateral 
sinus within 1.5 mm. of the bony surface at the operating point and rendering the ordinary 
mastoid operation impossible. At a position somewhat above the operating point the sulcus 
is less than ^ mm. from the bony surface : U, Upper, L. lower portion of the specimen; 
S.C, sigmoid sulcus; T, tympanum; At, attic; A, small antrum; S.S.M, spina supra- 
meatum. (Author's specimen.) 

of the operation. Hence the disposition has been to 
make the bone wound larger than formerly by chiseling 
away the overhanging edge of bone above and behind the 
meatus and also the root of the zygoma. Not only are all 
cell-spaces, if present in this locality, by this method of 
operating removed, but the mastoid antrum is thoroughly 



468 DISEASES OF THE NOSE, THROAT, AND EAR 

exposed and becomes the bottom of a shallow cup-shaped 
cavity from which exuberant granulations can readily and 
thoroughly be scraped away. The flatter wound is readily 
cleansed and dressed after the operation and the healing 
process somewhat shortened. 

In the tip of most mastoid processes there is usually a 
large cell even when the bone is of the small-celled diploetic 
type (Figs. 249, 250). It is best in all cases, therefore, 
to remove the cortex of the mastoid tip and thoroughly 
expose this large cell if it be present to inspection. If it be 
filled with pulpy granulations these should be scraped away 
until the normal bone beneath has been thoroughly cleansed 
and exposed. In a small percentage of cases abscess of the 
large cell in the tip of the mastoid results in perforation 
through the median wall and the gravitation of pus into the 
digastric fossa and beneath the sternocleidomastoid muscle 
into the deeper tissues of the neck. Under these circum- 
stances it is necessary to remove the entire tip of the mas- 
toid and thoroughly expose the abscess-cavity. The inci- 
sion through the skin should be lengthened along the an- 
terior border of the sternocleidomastoid muscle and the 
attachment of the muscle to the end of the tip and median 
surface of the tip of the mastoid severed with scissors held 
as close to the bone as possible, after which the tip is very 
readily removed with the rongeur forceps (Fig. 254). In- 
stances in which the median surface of the large cell at the 
tip of the mastoid has been perforated, with the result of 
the gravitation of pus into the digastric fossa and the deeper 
tissues of the neck, were first described by Bezold and are 
hence frequently referred to as Bezold cases. It was a 
neglected case of this type that is quoted from Pilcher. 
Cases of this type are characterized by a brawny swelling 
below and behind the mastoid, and movements of the neck 
are extremely painful to the patient. Not only is it neces- 
sary to remove the entire tip of the mastoid in such cases, 
but the abscess-cavity in the tissues of the neck should be 
thoroughly laid open by a free incision through the skin. 
The sternocleidomastoid is attached not only to the tip of 
the mastoid process, but to the base of the skull posteriorly, 
and severing its attachment to the mastoid does not appar- 



OPERATIONS UPON THE MIDDLE EAR 



469 



ently impair its functions. However, except in Bezold cases, 
it is manifestly not absolutely necessary as a mere matter of 
routine to remove in all cases the entire tip of the mastoid 
and expose the digastric fossa. 

If no softened spot or sinus is found upon the surface of 
the mastoid bone after denuding it of its epithelium it will 
be necessary to make an opening by means of the mallet 
and chisel. For this purpose the spina suprameatum or 
spine of Henle should be carefully located and preserved 




Fig. 260. — Lateral surface of a right adult temporal bone, showing superficial land- 
marks. The shadow indicates the position of the lateral sinus : A, Antrum ; in the triangle 
of MacEwen immediately in front is a well-developed spina suprameatum at the posterior 
superior border of the meatus ; T.A, T. T, upper surface of the tegmen antri and tegmen 
tympani. In some specimens the middle cerebral fossa extends as low down as the dark 
line immediately above the meatus, and hence chiseling cannot be carried above the level 
of this line without danger of entering the cranial cavity. (Author's specimen.) 



during the subsequent procedures of the operation to serve 
as a landmark. Some portion of the mastoid antrum will 
be found at a depth of from 12 to 22 mm. in a direction 
parallel to the meatus, immediately behind the spina supra- 
meatum, in a space called the suprameatal or triangle of Mac- 
Ewen (Fig. 260). If at a depth of 15 mm. or about f inch 
when chiseling through dense bone the antrum is not opened, 
the operator should proceed wdth great caution to avoid 



mjunng the facial 



canal or entering the cranial cavity, as the 



470 DISEASES OF THE NOSE, THROAT, AND EAR 

antrum may be small and easily overlooked. In some in- 
stances (Fig. 259) the lateral sinus is much further forward 
than is indicated by the shadow (Fig. 260), and to avoid the 
danger of injuring it the operator should keep as close to the 
meatus as possible when working his way toward the mas- 
toid antrum with a chisel or curet. In some instances, 
where the drum-head and ossicles are partially destroyed, a 
silver probe with its tip bent at a right angle may be carried 
through the canal into the vault of the tympanum and held 
in such a position as to serve as a guide. If the chiseling 
and cureting be continued in the right direction within the 
triangle of MacEwen, that is, parallel to the canal and a 
little upward, there is little danger of wounding any impor- 
tant structure before the probe is encountered. When chis- 
eling through sclerosed bones (Fig. 251), even though no 
cell structure nor pus, but only softened bone in the region 
of the antrum is encountered, the relief of all mastoid 
symptoms usually follows the operation. 

As the lateral sinus is sometimes very superficial and dis- 
placed far forward toward the meatus, the cortex of the 
mastoid is most safely removed by inserting a moderate-sized 
gouge immediately beneath the spine, and keeping as close 
to the meatus as possible, chiseling a long strip of bone down 
to the mastoid tip. It may be advisable to chisel a second 
groove parallel to the first. The depth of the grooves should 
be increased if necessary until cellular tissue is encountered, 
when the chisel may be discarded for a narrow curet (Fig. 
256), and the cellular tissue removed, all overhanging edges 
of the cortex being cut away with the rongeur as the opera- 
tion proceeds until the mastoid process has been thoroughly 
eviscerated and the antrum converted into a shallow cup- 
shaped cavity. 

After-tec hnic. — After the operation is completed the audi- 
tory meatus and wound should be irrigated freely with warm 
sterilized water. It is not advisable to use solutions of cor- 
rosive sublimate for this purpose while the patient is under 
ether, as the fluid may run through the Eustachian tube into 
the throat and an unknown quantity be swallowed. If neces- 
sary one or more sutures should be used to hold the auricle 
in position, the wound and auditory canal lightly packed 



OPERATIONS UPON PJIF. MIDDLE EAR 47 1 

with iodoform gauze, and a roller bandage applied over 
sterilized gauze and cotton. 

Twenty-four hours after the operation the dressing should 
be removed from the wound and the parts carefully in- 
spected. The parts should then be thoroughly douched 
with a I : 1000 bichlorid solution, the wound again packed 
lightly with iodoform gauze, and sterilized gauze, cotton, 
and roller bandage applied. If the wound be packed too 
firmly with the iodoform gauze during the first few days 
following the operation there is danger of injury of the 
facial nerve, with resulting transient paralysis of some of the 
facial muscles ; later on the wound may with advantage be 
packed more firmly. In some cases the wound does better 
if, after thoroughly cleansing, it be dusted with boric acid 
and packed either with sublimate or sterilized gauze. This 
is more especially the case if the lips of the wound appear 
sluggish and the exposed bone does not quickly cover itself 
with granulations. The presence of edema in the super- 
ficial tissues about the wound may render advisable the use 
of a wet sublimate dressing for from twenty-four to forty- 
eight hours. Sometimes exuberant granulations on the 
superficial edges of the wound will require removal with 
the curet or scissors, as the wound requires to be kept open 
until firmly healed from the bottom, a result that usually 
requires from three to four weeks. 

Usually recovery from a mastoid operation is uneventful. 
Pain and sleeplessness on the night following the operation 
may require the use of a small dose of chloral and bromid 
of sodium or even an opiate. Usually the temperature is 
practically normal and the patient entirely comfortable on 
the morning following the operation. If the evening tem- 
perature for the first three or four days reaches 100^ or 
even 101° F., it need occasion no anxiety. When the tem- 
perature remains normal for one or two days the patient 
may be allowed to sit up and move about in his room. 

Persistent pain and sleeplessness with high temperature 
following the operation may be due to a slight attack of 
local periostitis or to the fact that all the foci of inflamma- 
tion in the mastoid bone have not been reached by the 
chisel. 



472 DISEASES OF THE NOSE, THROAT, AND EAR 

, Accidents Occurring During the Mastoid Operation. — The 
middle cranial fossa may be opened, the posterior cranial 
fossa may be opened, and the lateral sinus exposed or 
wounded. One of the semicircular canals may be pene- 
trated. The facial nerve may be wounded or divided. 

Occasionally the middle cranial fossa extends downward 
to a level scarcely more than \ inch above the meatus (Fig. 
260). It is better, therefore, not to do any deep chiseling 
in this locality until the mastoid antrum has been located. 
After this has been accomplished and the cavity thoroughly 
exposed, it is, of course, easy to locate the exact position of 
the floor of the middle cranial fossa by means of a probe in 
contact with the tegmen or roof of the antrum. After this 
has been explored with the probe it is easy without the 
slightest danger of entering the middle cranial fossa to re- 
move the superficial bone, including the spina suprameatum 
above and behind the meatus, in order to secure a flat 
wound. However, if the middle cranial fossa be opened and 
the dura exposed, it is not usually a very serious accident, 
as the dura ordinarily granulates like the other portions 
of the wound, providing the operation is done with anti- 
septic precautions. It is perfectly justifiable when soft- 
ened bone is found in the vicinity of the tegmen to thor- 
oughly remove the diseased bone even if by so doing the 
dura is exposed, as by this procedure a small extradural 
abscess may be opened whose presence otherwise would not 
be suspected. Should pus be located between the skull and 
the dura the opening in the bone should be made suffi- 
ciently large to secure ample drainage, but exploration with 
the probe between the bone and the dura should be under- 
taken with extreme caution and gentleness, because the dura 
ordinarily attaches itself about such an abscess-cavity to the 
base of the skull, thus isolating the suppuration from the rest 
of the dural surface and preventing a general infection. 
However, considerations of this kind should not be allowed 
to interfere with opening the skull sufficiently to secure 
ample drainage. If the collection of pus be small and the 
mastoid wound flat, it probably will not be necessary or 
desirable to insert a gauze drain between the bone and 
the dura. 



OPERATIONS UPON THE iMIDDLI': EAR 473 

Opening the Posterior Cranial Fossa and Won?idi/ii^ the 
Lateral Sinjis Duri)ig the Mastoid Operatioii. — In diploctic 
and small compact mastoid bones the lateral sinus often 
occupies a position more anterior and superficial than is 
normally the case. In the bone shown in Fig. 259 a care- 
less operator might readily expose and open the lateral sinus 
with the chisel. In very rare instances the sinus is not 
covered by bone at all, but lies immediately beneath the skin 
and might be freely opened by the first stroke of the knife. 
However, even in extreme cases of anterior position of the 
lateral sinus, there is usually a sufficient space of compara- 
tively soft bone between the hard bone covering the sinus 
and that of the meatus for a careful operator to work through 
safely to the antrum with a curet or gouge. The position 
of the lateral sinus is often apparent after the cellular tissue 
has been cureted away, a distinct oval elevation of hard bone 
gradually shaping itself into view. This elevation is the 
hard bony wall of the sigmoid fossa in which the lateral 
sinus Hes. Should the bone in this locality be carious and 
soft it should be scraped away with the curet and the sinus 
exposed, because extradural abscess is somewhat common 
in this locality. When the lateral sinus is torn or cut during 
a mastoid operation it does not spurt like an artery, but a 
gush of blood wells out from the wound, pulsating with 
each heart-beat as it flows. The lightest pressure of the 
finger upon the bleeding sinus causes the hemorrhage to 
cease. 

When the lateral sinus is accidentally wounded during a 
mastoid operation a small piece of iodoform gauze should 
be placed on the sinus and held in position by the finger of 
an assistant and, if possible, the operation completed. The 
wound should then be firmly packed with iodoform gauze 
in such a manner as to control the hemorrhage and a firm 
roller bandage applied. The dressing should not be dis- 
turbed unless absolutely necessary before the third or fourth 
day. At this time, if the packing over the sinus is sloivly 
and gently removed, in all probability the hemorrhage will 
not reappear. Cases in which the lateral sinus has been 
accidentally wounded generally do well and make an un- 
eventful recovery. However, it is wise during the first few 



474 DISEASES OF THE NOSE, THROAT, AND EAR 

days to keep such cases under careful observation lest the 
bandage be displaced and a hemorrhage recur. 

Opciiing the Horizontal Semicircular Canal and Wounding 
the Facial Nerve. — The position of the horizontal semicir- 
cular canal and the facial nerve is shown in Figs. 173, 176, 
239, 240, 242, and 259. The aural portion of the facial 
nerve may be divided into a horizontal and a vertical por- 
tion (Figs. 173, 176, 239). The horizontal portion is em- 
bedded in a ridge of bone just above the oval window. The 
horizontal semicircular canal lies just above posteriorly. 
Both of the sestructures are embedded in ridges of ex- 
tremely hard bone. These ridges can frequently be seen in 
the radical mastoid operation as soon as the attic is well 
exposed, and hence the exact position of the nerve located. 
The simple mastoid operation, even when it is sufficiently 
complete to convert the antrum into a shallow cup in the 
bottom of the bone wound, does not expose the bony ridges 
containing the horizontal semicircular canal and the horizon- 
tal portion of the facial nerve. However, these structures 
lie so high up and so far forward that there is little danger 
of injuring them, except by a careless operator. Ordinarily 
the ridges of bone containing the horizontal semicircular 
canal and the horizontal portion of the facial nerve are 
sufficiently hard and thick to offer great resistance to 
an instrument, but occasionally the bone is very thin over 
the horizontal part of the facial nerve or may in part be 
lacking, so that the nerve lies just beneath the mucous 
membrane. Hence, if at the close of a simple mastoid ope- 
ration the aditus and attic are found to be full of exuberant 
granulations and the small curet (Fig. 229, a^ is used to 
remove them, it should be employed with great gentleness 
when scraping the inner median wall of the aditus. 

It is, however, the vertical portion of the nerve that is 
most liable to injury during a mastoid operation. Because 
of the oblique position of the membrana tympani the annu- 
lus approaches in some instances as close to the nerve as J 
mm. at a position opposite the malleus tip. The operator, 
therefore, should observe considerable caution in removing 
much bone in this locality. 

When the bone forming the facial canal is necrosed it is 



INl'RACRANIAL COMPLICATIONS OF OTIC DISEASE 475 

difficult to avoid injurin<^ the nerve during its removal, and 
hence, if the nerve is partially paralyzed before an opera- 
tion, it is well to caution the patient that the operation may 
fail to relieve this condition or even make it worse. A sim- 
ple bruising of the nerve during a mastoid operation is fol- 
lowed by transient paralysis of the muscles of one side of 
the face. The paralysis is usually worse in the muscles of 
the lower portion of the face because that part of the face 
is supplied by the more superficial fibers of the nerve. 
Cases of this kind and paralysis resulting from too tight 
packing of the mastoid wound almost invariably end in 
complete recovery. It is stated that the nerve may be com- 
pletely severed without causing permanent facial paralysis. 

INTRACRANIAL COMPLICATIONS OF OTIC DISEASE 

These are pachymeningitis or subdural abscess, lepto- 
meningitis, serous and purulent; cerebral and cerebellar 
abscess ; and thrombosis of the sinuses. 

Subdural or Extradural Abscess. — Pachymeningitis is an 
inflammation of the dura mater, also called external men- 
ingitis and perimeningitis. Generally it is the result of in- 
fection from caries. Fortunately, under such circumstances, 
the dura generally forms adhesions around the carious area 
of bone and thus prevents the spread of the infection. The 
disease then becomes a subdural abscess. The usual sites 
of subdural abscess following aural suppuration are the 
groove for the lateral sinus and the superior surface of the 
petrous bone. Such collections of pus can sometimes be 
located and evacuated by surgical intervention. Cases of 
spontaneous evacuation through the middle ear have been 
reported. 

It is not very unusual during a mastoid operation to open 
such an abscess w^hen removing carious bone with a curet. 
When the dura is thus exposed a probe should be used 
with great gentleness in order not to break up any adhesions 
that have formed betw^een the dura and bone about the 
abscess-cavity. At the same time the amount q>{ bone re- 
moved should be sufficient to permit ample drainage from 
the infected dural surface, which is usually covered by gran- 



4/6 DISEASES OF THE NOSE, THROAT, AND EAR 

ulations. The necessity for exposing a considerable area 
of dura mater by cureting away carious bone need occasion 
the operator no uneasiness, as the dural surface granulates 
and heals with the rest of the mastoid wound. 

Leptomeningitis is an inflammation of the pia and arach- 
noid in contradistinction to pachymeningitis, which signifies 
an inflammation of the dura; although, as ordinarily em- 
ployed, the word meningitis has practically the same signif- 
icance as leptomeningitis, which may be either serous or 
purulent ; general, involving the brain and cord, or local, 
involving, for example, only a portion of the convex surface 
of one side of the brain. 

The avenues of infection in otic leptomeningitis are the 
tegmen, the sigmoid sinus, the carotid canal, the labyrinth, 
the facial canal, and the lymphatics or blood-vessels. It 
generally occurs as the result of caries or necrosis. 

Serous leptomeningitis begins as a general hyperemia of 
the pia and arachnoid, followed by a serous exudation. The 
dura and the ventricles become distended by the exudate 
with resulting pressure symptoms. 

Slight cerebral irritation, especially in children, probably 
meningitis, frequently accompanies acute inflammation of 
the middle ear. The symptoms are localized headache re- 
ferred to the temporal or occipital region, which may be 
tender on percussion. Morning and evening fever is some- 
times present and, in infants, convulsions. These symptoms 
may disappear within a short time as the result of purgation 
with calomel, bromid of potash, and an ice-cap, or the pulse 
may become rapid, the temperature rise, the pupils cease to 
react to light, and hebetude with loss of consciousness may 
occur. In a boy about fourteen years of age, seen at the 
Philadelphia Hospital, who presented these symptoms on 
the fifth day of a purulent otorrhea, immediate relief fol- 
lowed the withdrawing of \\ ounces of cerebrospinal fluid 
by lumbar puncture. 

Lumbar puncture is performed as follows : The patient 
either sits up or lies upon the side, with the back arched 
and the knees flexed against the abdomen. The spine of the 
fourth lumbar vertebra should be located (a line drawn from 
one posterior superior spine of the ilium to the other passes 



INTRACRANIAL COMPLICATIONS OF OTIC DISEASE 477 

across it) and the puncture made J inch to one side, at the 
level of its lower end. The needle should be inclined at an 
angle of about 45 degrees to the surface of the skin, and 
should be thrust in a distance of from 2\ to 3 inches. The 
most scrupulous asepsis must be observed. The spinal 
fluid flows readily, either in a stream when the pressure is 
high or drop by drop if it is normal. In purulent menin- 
gitis it is cloudy and contains pus-cells ; in tuberculous 
meningitis it is usually clear ; in cerebral hemorrhage it may 
be bloody, but as admixed blood may be due to the injury 
of a vessel by a needle, the diagnosis should be made with 
caution. The quantity obtained varies from 2 or 3 to 80 or 
90 ccm. — /. c'., from a few drops to 3 fluidounces. 

Purulent Leptomeningitis. — In purulent meningitis the 
exudate becomes cloudy and mucopurulent in appearance 
from the presence of leukocytes. The bacteria present 
vary and are usually those found in the otorrhea that has 
caused the condition. 

Pathology. — The vessels of the pia and arachnoid are in- 
fected and the membranes become cloudy. A serofibrin- 
ous or purulent exudate distends the dura or may exist 
only in patches. The cerebral membranes may be involved 
either as a whole or in part. In severe cases those of the 
spine are affected as well. The brain or cord may be 
softened in places or, as Ander's states, no gross lesions, 
either of meninges, brain, or cord, even microscopic, are 
found post mortem in many cases presenting the clinical 
picture of meningitis. 

Symptoms. — The temperature is usually from 101° to 
105° F., and exhibits but slight variation during the day and 
night. There are severe headache, photophobia, vomiting, 
and localized or general convulsions. Dehrium is common 
in young subjects, but in adults the patient is at first wake- 
ful, but slowly passes into a condition of fatal coma. Pa- 
ralysis of the pupil, strabismus, and ptosis are the most 
frequent forms of paralysis present. 

There is often retraction and fixation of the head. Re- 
flexes are at first increased and later diminished or absent. 
There is hyperesthesia of the skin. The pulse, at first full 
and rapid, later in the disease is slow, but becomes again 



478 DISEASES OF THE XOSE, THROAT, AND EAR 

rapid in the last stage. The pupils finally become dilated. 
There is general paralysis and death, occurring as early as 
two or three days or the fatal termination may be post- 
poned for some weeks. 

Treatment. — Where the symptoms are simply those of 
cerebral irritation, perfect rest in bed, large doses of the 
bromids, purgation with small, frequently repeated doses of 
calomel and saHnes. Sometimes the local abstraction of 
blood from the ear by means of leeches and an ice-cap are 
effectual in checking the attack. 

Where lumbar puncture gives relief, it should be repeated 
as often as deemed necessary. The procedure is of value 
not only as a method of treatment, but as a matter of diag- 
nosis. The amount of fluid flowing freely through the 
needle indicates the degree of pressure, and the microscope 
will disclose the presence of pus and the bacteria causing 
the infection. 

As purulent leptomeningitis is invariably fatal unless 
checked in time, surgical measures, to be of value, must be 
instituted early. When there is no doubt as to the diag- 
nosis the mastoid antrum should be opened, and if the 
amount of disease met with is not sufficient to account for 
the symptoms, the cranial cavity also, in search of an extra- 
dural abscess. Even if no pus be found, the opening into 
the cranium with the consequent local depletion and relief 
of tension is the best possible treatment and has been fol- 
lowed by recovery in some severe cases. 

Abscess of the Cerebrum and Cerebellum. — Abscesses of 
the brain following otitis are probably invariably located on 
the affected side. They may be single or multiple. It is 
the white substance that is generally involved. The bacteria 
found in the pus are various, generally those found in the 
discharges of the ear that has been the cause of the infec- 
tion. Saprophytes or the micro-organisms developing in 
putrid material are sometimes present. 

The disease is generally the result of chronic purulent 
otitis and necrosis. A localized pachymeningitis as the 
result of adhesions about the necrosed bone prevent the 
spread of the infection and a subdural abscess is formed, 
which in turn infects the brain substance. 



INTRACRANIAL COMPLICATIONS OF OTIC DISEASE 479 

Symptoms. — Cerebral abscess may present no symptoms 
for many months, but at any moment acute meningitis may 
occur or increased intracranial pressure result in coma and 
death. 

In the early stages the diagnosis is usually not easy. 
Severe, deep-seated pain and tenderness over the temporal 
region, optic neuritis, and localized paralysis may be present 
to a greater or less degree. There may be a sudden rise of 
temperature lasting for a short time, followed by normal or 
subnormal temperature, mental dulness, slowness of speech, 
increasing cachexia and debility, ending sometimes in coma. 

The symptoms of cerebellar abscess are more obscure 
even than in cerebral abscess and the diagnosis extremely 
difficult. Subjects of cerebellar abscess may present ab- 
solutely no symptoms, and yet suddenly die as the result 
of the rupture of the abscess into the fourth ventricle. 

Treatment. — Surgical intervention in all cases of intra- 
cranial suppuration is the only adequate remedy. As a 
general rule the cranial cavity should only be entered after 
removing diseased structures from the middle ear. After 
the antrum and attic have been cleansed the original skin- 
wound is enlarged to a sufficient degree by an incision 
directly backward and the periosteum detached. The 
groove for the lateral sinus is then cautiously opened by 
means of a mallet and chisel and the sinus examined care- 
fully for thrombus. If no clot is found the opening into 
the skull is enlarged by means of the trephine, chisel, 
or cutting forceps (upward to reach the middle or down- 
ward to reach the posterior cranial fossa). While pro- 
ceeding with the operation it is possible that an extradural 
abscess may be opened. Under such circumstances free 
drainage should be secured and the wound dressed. If no 
such collection of pus is discovered while enlarging the 
cranial opening a flexible grooved director should be passed 
in different directions between the dura and the skull in 
search of pus, and finally the tegmen of the antrum and 
attic removed, as an extradural abscess is not infrequently 
located upon this thin plate of bone. 

In using a trephine for exploration of the cranial cavity 
one of at least \ inch should be employed. If the center 



480 DISEASES OF THE NOSE, THROAT, AND EAR 

pin of a trephine of this size be placed upon the bone \ inch 
behind the center of the meatus and \ inch above Reed's 
base Hne (which is an imaginary line passing through the 
center of the meatus, touching the lower border of the orbit 
and extending backward to the occipital protuberance), 
w^hen the disk of bone is removed from the skull it will 
expose the lateral sinus, which usually is reached more 
quickly than when the chisel alone is used. 

For epidural abscess the center pin of the trephine should 
be placed upon the skull i inch above the center of the 
meatus. The resulting opening in the skull, if sufficiently 
enlarged with the rongeur forceps, will enable the operator 
to explore the surface of the tegmen of the antrum and 
tympanum. The posterior cranial cavity may be explored 
by means of a trephine opening if the center pin of the in- 
strument be placed i^ inches behind the center of the 
meatus and \ inch below Reed's base line. Both the middle 
and the posterior cranial cavities can be explored by means 
of a trephine opening if the center pin of the instrument 
be placed \\ inches behind the center of the meatus and \\ 
inches above Reed's base line. As the skull in this position 
is comparatively thin, it is easy from such a trephine open- 
ing with the rongeur forceps to tear away the skull either 
downward into the posterior fossa or forward into the 
middle fossa. 

If cerebral abscess be present near the surface the dura 
will bulge without pulsation into the wound. Selecting a 
spot, a small sterilized hollow needle is carefully inserted 
in the brain. Should pus escape or the needle yield a 
fetid odor when withdrawn, the dura is incised and a trocar 
passed in the required direction. If a definite pus-cavity be 
emptied of its contents it should be washed out gently with 
a warm, steriHzed, saturated solution of boric acid, a drainage- 
tube inserted into the tract of the trocar, the wound closed, 
and a dressing applied. The abscess-cavity should be 
washed out each day with warm borated water and the 
drainage-tube shortened at each dressing until the abscess- 
cavity has closed. 

Whiting has devised an instrument which he calls an 
encephaloscope, through which the interior of the abscess- 



INTRACRANIAL COMPLICATIONS OF OTIC DISEASE 48 1 

cavity can be inspected. The instrument somevvliat resem- 
bles an car speculum and through it the abscess-cavity can 
be irrigated and packed with gauze without injuring the 
normal brain tissue. 

An abscess-cavity, having been located by means of a 
hollow needle or grooved director, the brain tissue is incised, 
the encephaloscope inserted, and the cavity irrigated. Iodo- 
form gauze, previously saturated with a solution of peroxid 
(1 : 4 of water), is then gently packed into the cavity and 
the encephaloscope withdrawn. The packing is changed 
each day until the abscess-cavity has closed. The wound 
in the dura is then allowed to heal and the skull wound 
to fill with granulations and close as in a radical mastoid 
operation. 

If exploration of the middle cranial fossa does not yield 
results sufficiently definite to account for the symptoms the 
wound in the skull is enlarged downward sufficiently to 
permit access to the structures below the tentorium. The 
exploration in this region should be conducted on the same 
general principles as in the middle cranial fossa, but, of 
course, the utmost care should be exercised in the use of 
the exploring needle. 

Sinus Thrombosis. — The lateral sinus may be infected by 
way of the superior petrosal sinus as the result of attic sup- 
puration. Usually, however, the infection proceeds from 
the mastoid cells by way of the numerous small veins that 
reach the sinus through the bone. An early stage of the 
process is the occlusion of the sinus by a firm fibrinous clot 
which may extend backward as far as the torcular He- 
rophiU or downward into the internal jugular vein. The de- 
velopment of septic bacteria within the clot leads to general 
septic infection ; and if the patient survives long enough, 
secondary abscesses appear in various organs of the body, 
septic pneumonia being the most common complication ; 
but it should not be forgotton that sinus thrombosis may 
produce secondary sinus thrombosis and brain abscess on 
tJie opposite side. Occasionally sinus phlebitis occurs as the 
result of the contact of necrosed bone, so that the sinus is 
easily torn during the mastoid operation, with resulting 
severe hemorrhage. 

31 



482 DISEASES OF THE NOSE, THROAT, AND EAR 

Symptoms. — The progress of the disease is exceedingly 
insidious and the symptoms vague. The most reliable is a 
sudden great rise of temperature, followed by an abrupt 
fall at successive intervals as the result of the breaking 
down of a portion of the clot and the passage of septic 
material into the general circulation. Unless the thermom- 
eter be used every two or three hours during the day the 
characteristic variation in temperature may readily escape 
notice. In uncomplicated cases intracranial symptoms, such 
as severe headache, paralysis, or convulsions, are absent. 
Sooner or later symptoms of general sepsis occur — asthenia, 
emaciation, an ashy hue of the skin, and profuse perspira- 
tion. Severe rigors may or may not occur. 

A certain number of cases of primary thrombosis recover 
spontaneously, although it is impossible to state how many 
die subsequently of secondary cerebral abscess and other 
sequelae of the disease. 

Treatment. — Early operation if the diagnosis is certain. 
The only therapeutic measures of value are those which 
combat the asthenia. Nutritious food, by mouth or rectum, 
large doses of quinin, and alcoholic stimulants. 

When the mastoid antrum has been previously opened 
the original opening should be enlarged backward and 
downward, and the dura exposed as far as the occipitotem- 
poral suture. After the sinus has been exposed the presence 
of a clot may be ascertained by the sense of touch or by in- 
serting a sterilized hypodermic needle. If a thrombus is 
present pus or foul-smelhng blood are usually withdrawn, 
but if the channel is normal, fluid blood alone enters the 
syringe. 

To remove an infectious thrombus the sinus is freely 
incised and its cavity emptied by the delicate use of a curet 
until decidedly free hemorrhage supervenes. The cavity 
should then be packed with iodoform gauze. 

When the clot has extended downward into the jugular 
vein, as evidenced by tenderness along the anterior border 
of the sternocleidomastoid muscle and a cord-hke structure 
occupying the position of the vein, the vessel should be 
exposed, laid open between two ligatures, and the clot re- 
moved as from the lateral sinus. Any large tributary vein 



JNl'RACRANIAL COM PLICATIONS OF OTIC DISK ASK 483 

should, however, be tied before dividing the jugular. If the 
operation is performed before secondary abscess or profound 
systemic infection has occurred it may result in the re- 
covery of the patient. 

Facial paralysis or Bell's palsy is a paralysis or paresis of 
some or all of the muscles supplied by the facial nerve. In 
the graver form of the disease there is complete immobility 
of the muscles of expression of the affected side of the face, 
slight deafness from involvement of the stapedius muscle, 
unilateral paralysis of the uvula and the palate, and unilat- 
eral impairment of the sense of taste at the anterior two- 
thirds of the tongue, through involvement of the chorda 
tympani nerve. 

Etiology. — The disease may be central^ as the result of 
basilar meningitis, tumors or exostoses at the base of the 
brain, syphilitic lesions in this situation, or aneurysm of 
the vessels at the base of the brain. Not a {q.\n cases 
are apparently rheumatic and result from exposing one 
side of the face to a draft, sitting in a damp room, or 
suddenly chilling the body when overheated. The disease 
is of interest to the aurist chiefly from the fact that it may 
occur as a complication in a large variety of middle-ear affec- 
tions, or as a result of the nerve being bruised or wounded 
during the course of an operation upon the middle ear, or 
from packing the wound too tightly after the operation. It 
should be borne in mind that the facial canal arches back- 
ward over the oval window and then descends almost per- 
pendicularly through the temporal bone. As the result of 
the oblique position of the drum-head the facial canal ap- 
proaches in some skulls to wdthin i millimeter of the annu- 
lus, at a position about midway between the floor and the 
roof of the canal. The pressure of a polypus or an accu- 
mulation of epithelium or cerumen on the nerve through 
the thin bone in this region is sufficient in some cases to 
produce paralysis of the facial nerve, usually remediable by 
the removal of the offending body. General h% however, 
the facial nerve in its passage through the middle ear is de- 
fended by comparatively thick and hard bone. In some in- 
stances, however, the bone covering the nerve above the oval 
window is as thin as tissue-paper, and congenital dehiscences 



484 DISEASES OE THE NOSE, THROAT, AND EAR 

of the bone of this region are by no means uncommon, so that 
the nerve in such cases lies almost immediately under the 
mucous membrane. Such a congenital lack of bone in this 
position explains the occasional occurrence of facial paraly- 
sis as the result of simple non-suppurative catarrh of the 
middle ear. Suppuration of the middle ear is a common 
cause of facial paralysis, sometimes so slight that the lack 
of mobiHty of the affected side of the face can be detected 
only by the closest scrutiny ; at other times the paralysis is 
complete and involves all the muscles supplied by the facial 
nerve on the affected side of the face. Such cases are doubt- 
less the result of pressure on the nerve caused by spreading 
of the inflammation from the mucous membrane to the bony 
wall of the facial canal and the sheath of the nerve, and are 
the more favorable instances of the disease ; for after the 
subsidence of the inflammation and the absorption of the 
exudation the facial paralysis disappears spontaneously. 
Facial paralysis occurs during caries and necrosis of the 
temporal bone if the inflammation and destruction extend 
to the nerve ; but caries of the facial canal is not always 
accompanied by paralysis, for instances are on record where, 
as the result of caries, the nerve has been exposed and 
bathed in pus for months without the occurrence of facial 
paralysis. Facial paralysis in more than one instance has 
followed the simple removal of the drum-head and larger 
ossicles, and is not uncommon as the result of the mastoid 
operation. Most of these cases ultimately completely re- 
cover, sometimes even when there was reason to suppose 
that the nerve had been completely severed. When work- 
ing in the neighborhood of the facial nerve some operators 
are in the habit of directing their assistant to watch for 
slight twitching of the muscles of the face, and desist im- 
mediately should this occur. When twitching of the face 
occurs under these circumstances it is an indication that 
mischief has already been done to the nerve, and, unless 
absolutely necessary, the vicinity of the facial nerve should 
be studiously avoided during the Stacke and mastoid opera- 
tions. Many operators are accustomed, when performing 
Kiister's operation, to guard the position of the facial canal 
with a bent probe or similar device introduced into the tym- 



INrKACRANIAL COMPLICATIONS OF OTIC DISEASE 485 

panum through the opening in the mastoid bone. Doubt- 
less this is a useful procedure in some instances, but the use 
of the probe in this manner is apt to produce a misleading 
sense of security, and there are reasons for believing that in 
some instances the injury to the nerve has been done by the 
slipping of the probe entrusted to the hand of an assistant 
rather than by the instrument in the hands of the operator. 
The wound in the bone after a middle-ear operation should 
be only lightly packed with gauze, especially in the case of 
children. 

Symptoms. — Double facial paralysis is somewhat rare. 
When it does occur and is complete the face is absolutely 
expressionless and as immobile as that of a graven image. 
In a case observed by Troltsch the cornea was partly dried 
as the result of ectropion of the lower lid, the under lip 
hung loosely down, and the chin had to be pushed up in 
speaking and eating. Facial paralysis sometimes appears 
quite suddenly, but in many instances there are premonitory 
symptoms of pain in the side of the head and twitching of 
the muscles of the side of the face. A patient suffering 
from complete facial paralysis is unable to wrinkle the brow 
or close the eyes, although the upper eyelid often descends 
somewhat during the effort. On account of the paralysis 
of the orbicularis the puncta lacrimalia drop away from 
the globe and the eye is constantly suffused with tears, and, 
being no longer protected from dust and cold by the mo- 
tionless lids, soon becomes inflamed. The ala nasi on the 
affected side cannot be distended during inspiration and 
hence nasal respiration and the sense of smell are impaired 
on the affected side. The angle of the mouth drops a little 
and is drawn somewhat toward the unaffected side. While 
drinking, some of the fluid dribbles from the corner of the 
mouth ; and the food collects between the cheek and the 
teeth, so that it is necessary while eating to remove it from 
time to time with the finger. If the cheeks are distended 
air escapes at the corner of the mouth, and because of the 
paralysis of the palate-muscles it is usually necessary to 
employ the Eustachian catheter if the ears require inflation. 
The hearing is usually somewhat impaired as the result of 
paralysis of the stapedius muscle, but sometimes becomes 



486 DISEASES OF THE NOSE, THROAT, AND EAR 

still worse, if care is not exercised, from Eustachian salpin- 
gitis resulting from the paralysis of the tubopalatine muscles. 
When an attempt is made to smile the entire lower part of 
the patient's face seems to move toward the unaffected side. 
If recovery does not occur the affected muscles sometimes 
undergo atrophy, so that the affected side of the face looks 
smaller than the other. Contractures and spasms of the 
affected muscles in some cases finally occur, the spasms 
being clonic in character and not painful. As the result of 
contracture the angle of the mouth is sometimes drawn up- 
ward and the nasolabial fold deepened until at the first 
glance it would appear as if the unaffected side of the face 
were the paralyzed one. 

In many instances the paralysis of the facial muscles is 
not complete, the muscles of the lower portion of the face 
being the ones most affected. In some instances, however, 
the muscles of the lower portion of the face and those of 
the forehead as well will be almost completely paralyzed, 
while the eye can still be completely shut, although with 
considerable effort. As this form of paralysis is the most 
common after middle-ear operations, it would appear that 
the fibers of the nerve supplying the muscles of the lower 
part of the face and the forehead occupied a more super- 
ficial position within the facial canal than those supplied to 
the orbicularis palpebrarum. 

Diag7iosis. — In the variety of the disease due to a central 
lesion the paralysis usually occurs after an apoplectic seiz- 
ure and other muscles are generally affected besides those 
of the face. Generally in such cases the muscles of the 
forehead and the orbicularis palpebrarum are affected to a 
considerably less degree than those of the other parts of 
the face, and the electric contractility of the affected mus- 
cles is not affected in the slightest degree, no matter how 
profound the paralysis may be. In a certain proportion of 
cases the unilateral paralysis of the palate, impairment of the 
function of taste at the anterior two-thirds of the tongue, 
and the presence of a disease of the middle ear that is 
capable of causing a lesion of the seventh nerve are points 
that will help to clear up the diagnosis. In peripheral facial 
paralysis it is sometimes possible to determine with a cer- 



INTRACRANIAL COMR/.ICA TIONS OF OTIC DISEASE 4<S7 

tain amount of accuracy the portion of the seventh nerve 
in which the lesion has occurred. If the lesion is above 
the <;eniculate gan<^lion there will be paralysis of all the 
facial muscles and those of the palate and uvula, with dis- 
turbance of hearin<^ ; but the sense of taste will be unim- 
paired, because the chorda tympani nerve enters the facial 
at the geniculate ganglion. If the lesion is between the 
geniculate ganglion and the point at which the nerve to the 
stapedius muscle is given off there will be paralysis of the 
facial nmscles, disturbance of hearing, and impairment of 
the sense of taste, but the movements of the soft palate 
will remain unimpaired because its motor fibers are supplied 
from the geniculate ganglion. If the lesion is situated be- 
tween the point where the stapedius nerve is given off and 
the point where the chorda tympani leaves the nerve, the 
former symptoms will be present, with the exception that 
there will be no disturbance of hearing ; and if the lesion is 
below the point where the chorda leaves the facial nerve 
there will simply be paralysis of the muscles of one side 
of the face. In order that the above should be practical 
for purposes of diagnosis it is necessary that the lesion 
should be sufficiently great to involve all the fibers of the 
nerve, which, of course, is not always the case. 

The prognosis depends upon the nature of the lesion pro- 
ducing the facial paralysis. When a portion of the nerve 
has sloughed away as the result of caries of the temporal 
bone recovery from facial paralysis is not to be expected, 
and where the nerve has been completely divided during a 
middle-ear operation complete recovery rarely occurs. 
Cases of paresis of the facial nerve and cases where only a 
part of the muscles of the face are involved usually result 
in complete recovery. The development of contractures 
and spasms is a most unfortunate event, as no cases where 
this occurs recover from the facial paralysis ; and consider- 
able deformity of the face is usually the result of the con- 
tractures and spasms. When the electric excitability of the 
nerve and muscles remains unchanged spontaneous recov- 
ery in from three to eight weeks may be expected, provid- 
ing the middle-ear disease that produced the lesion of the 
nerve ceases to be an active factor in the case. In many 



DISEASES OF THE NOSE, THROAT, AND EAR 

cases the excitability of the nerve and muscles to the 
Faradaic and galvanic currents begins to diminish within a 
few days of the onset of the paralysis, and is entirely lost 
at the end of a week or ten days ; and this extinction of 
electric excitabiHty continues until the patient begins to re- 
cover. Usually, in such cases, the patient is able to pro- 
duce voluntary movements of the paralyzed muscles before 
the nerve begins to react to electric stimuli. The case 
should not be regarded as hopeless when electric excita- 
bility of the affected muscles is entirely lost for a short 
period ; but such cases make a tedious recovery, and a 
period of from six to nine months usually elapses before a 
cure of the paralysis occurs. 

Treatment, — If diseased, the middle ear should, of course, 
receive appropriate local treatment. In rheumatic cases 
and those resulting from disease of the middle ear it is well to 
place the patient upon full doses of iodid of potassium and 
an ointment composed of equal parts of mercurial, iodin, and 
belladonna ointments should be rubbed into the skin over 
the mastoid and below the ear sufficiently often to keep the 
parts slightly sore to the touch. After from one to three 
weeks have elapsed and reaction has set in, it is well to 
begin the use of electricity, preferably the Faradaic current 
to the affected muscles, but in some cases better results are 
obtained from the employment of the galvanic current. A 
weak galvanic current may be sent along the affected nerve- 
trunk by placing a medium-sized electrode over each ear 
(the negative on the affected side), and passing a current 
between them. The Faradaic current may be applied to the 
affected muscles by placing a small electrode over them in 
turn ; or the electrode may be passed along a line in front 
of the auricle in order to reach the fibers of the pes an- 
serinus where they cross the side of the face. The current 
should be of sufficient strength to produce contractions of 
the affected muscles, and the sittings should last not longer 
than ten minutes every day or every other day. 



DISEASES OF THE PERCEPTIVE APPARATUS 489 



DISEASES OF THE PERCEPTIVE APPARATUS 

Diagnosis Between Middle-ear Deafness and that Resulting 
from Disease of the Internal Ear. — The diacniosis is made 
from the history of the case and by means of tuning-forks. 
Sudden deafness without pain is usually the result of im- 
pacted cerumen or of disease of the receptive apparatus of 
the ear. In most cases of long-continued disease of the 
middle ear the functions of the labyrinth become impaired 
because of the extension of the disease into the vestibule. 
It should be borne in mind that there are a few very short 
rods at the commencement of Corti's organ near the vesti- 
bule and that these rods are set in vibration by high-pitched 
sounds. Hence, when disease of the middle ear has ex- 
tended from the middle ear into the labyrinth, hearing is 
greatly impaired for high-pitched notes. 

A vibrating tuning-fork with its handle upon the mastoid 
is heard longer in middle-ear disease than if the middle ear 
were normal. If, however, the functions of the labyrinth 
are impaired the reverse is the case. A vibrating tuning- 
fork with its handle upon the vertex or forehead is heard 
best in the deafer ear in cases w^iere the functions of the 
receptive apparatus are unimpaired (Weber's method). The 
sound of a vibrating tuning-fork is heard longer when its 
tines are at the auditory meatus than when the handle is 
pressed upon the mastoid (Rinne's test, positive) by nor- 
mal ears and by ears in which deafness is mainly the result 
of impairment of the functions of the receptive apparatus. 
Rinne's test is negative in cases where the deafness is due 
to impacted cerumen or disease of the middle ear. 

It must not be supposed that tests with the tuning-fork 
are infallible ; for example, in cases in which the capsular 
ligament around the stapediovestibular joint has become 
stiff as the result of disease, it is easy to understand how 
the stapes can become fixed in the oval window as the re- 
sult of a blow on the side of the head or the concussion 
produced by the unexpected discharge of firearms. Under 
such circumstances suspension of the function of hearing 
will result from suddenly increased interlabyrinthine press- 
ure. The symptoms under such circumstances would all 



490 DISEASES OE THE NOSE, THROAT, AND EAR 

point toward disease of the labyrinth, and yet the hearing 
may become nearly normal as the result of vigorous in- 
flation of the middle ear by Politzer's method. It is evi- 
dent that in a case of this kind there was no actual disease 
of the labyrinth. 

Anemia of the labyrinth may be part of a general anemia 
or due to some local cause affecting the blood supply, such 
as tumors of the brain, endocarditis, osteosclerosis, or em- 
bolism of the auditory artery. 

Syinptojns. — After profuse hemorrhage from any cause 
there is tinnitus, vertigo, and nausea as the result of anemia 
of the labyrinth. These symptoms are made worse by sit- 
ting or standing and are decidedly ameHorated by lying 
down. The same is true of anemia of the labyrinth from 
other causes than hemorrhage. In anemia of the labyrinth 
the acuteness of hearing is more or less impaired, both for 
aerial and bone-conduction. 

Treatment is addressed to the general condition of the 
patient. 

Hyperemia of the labyrinth may result from most of the 
acute infectious diseases, middle-ear inflammation, some in- 
tracranial diseases, valvular disease of the heart, the meno- 
pause, plethora, gout, alcoholism, quinin, amyl nitrite, sali- 
cylic acid compounds, calcium chlorid, the irritation result- 
ing from long use of the telephone receiver, loud noises, 
vasomotor disturbances, etc. 

The symptoms are similar to those of anemia, except that 
they are intensified by the Jiorizontal position. The auricle, 
auditory canal, and drum-head may visibly participate in the 
hyperemia. Occasionally individuals are encountered in 
whom a few grains of quinin or salicylate of sodium will 
produce visible hyperemia of the auricle, canal, and drum- 
head ; also tinnitus, presumably from hyperemia of the 
labyrinth. 

The treatment is systemic. The symptoms are made 
worse by inflation and massage. Relief of tinnitus may be 
obtained from the bromids or hydrobromic acid, but com- 
paratively large doses (20 to 30 gr. three times a day) are 
required. 

Hemorrhage into the labyrinth may occur as the result of 



I 



DISEASES OF THE PERCEPTIVE APPARATUS 49 1 

degeneration of the blood-vessels, traumatism, hyperemia, 
concussion from explosions, etc. 

The syniptoDis are sudden deafness, nausea, syncope, and 
vertigo, with a tendency to fall toward the affected side. 

ProgJiosis. — If the hemorrhage is small it may be com- 
pletely absorbed with a restoration of the normal functions 
of the ear, but should the extravasation undergo fibrous de- 
generation the partial deafness will be permanent. Tinnitus, 
vertigo, and nausea, however, will disappear. 

Treatment consists in free catharsis and absolute rest in 
bed. Pilocarpin hydrochlorate may be given in y^g-gr. doses 
twice a day for five or six days or longer if it produces a 
decided improvement in the aural symptoms. lodid of 
potassium should be given in conjunction with or after the 
use of pilocarpin in 10- or 15-gr. doses three times a day 
or, if there is a history of syphilis, the dose should be 
further increased. After the lapse of some months quinin 
may be given slightly above the tonic dose to increase the 
supply of blood to the labyrinth and promote absorption if 
deafness and tinnitus still persist. 

Significance of a Discharge of Blood from the Internal 
Ear. — Occurring after traumatism a discharge of blood from 
the internal ear through the tympanum and external audi- 
tory canal indicates fracture of the base of the skull. An 
effusion of blood may occur within the labyrinth and cause 
complete disintegration of this organ. 

Concussion of the Labyrinth. — The symptoms are sudden 
deafness following concussion or a blow, without visible local 
injury. Tinnitus is usually present. The prognosis is un- 
favorable, but y^g- to \ gr. of pilocarpin should be injected 
subcutaneously each day until symptoms of weakness of 
the patient occur or it is manifest that the treatment is un- 
availing. 

Hysteric deafness is a somewhat rare symptom occurring 
in hysteric women. The deafness may be complete, lasting 
for several hours or days. Treatment is the same as for 
other hysteric conditions. 

Syphilis of the Internal Ear. — Plastic exudations may 
occur within the labyrinth similar to those occurring in 
plastic iritis. The disease is ushered in by loud subjective 



492 DISEASES OF THE NOSE, THROAT, AND EAR 

noises, deafness soon following. There is usually a notice- 
able disturbance of the patient's gait and he complains of 
constant dizziness. The prognosis is not altogether un- 
favorable if vigorous antisyphilitic treatment is begun early. 
One case observed by the writer at the Medico-Chirurgical 
Hospital made a complete recovery, although when first seen 
some months after the onset of the disease the vertigo was 
present to the extent that the man staggered as if intoxi- 
cated. 

Metastasis may occur in parotitis or mumps to the laby- 
rinth, with an exudation of a plastic material, the symptoms 
being deafness, tinnitus, and vertigo. If the affection is 
treated early, before the organization of the plastic material, 
with hypodermic injections of pilocarpin the prognosis is not 
altogether unfavorable. 

"Meniere's disease" is a name given to a group of symp- 
toms which may be caused by various affections of the 
labyrinth, the acoustic nerve, or the central nervous system, 
usually apoplectiform in character. There are sudden loss 
of hearing, tinnitus, and vertigo to such a degree often that 
the patient is unable to maintain his balance and falls to the 
ground. 

Usually the more alarming symptoms pass away within a 
few days, leaving, however, some deafness, tinnitus, and 
vertigo, which may remain for years, the deafness gradually 
getting worse until it is complete. 

Treatment. — After the subsidence of acute symptoms 
iodid of potassium may be administered in doses of from 5 
to 15 gr. three times a day and compound iodin ointment 
may be rubbed into the tissues about the ear. A hypo- 
dermic injection of pilocarp^n, y^ to ^i^, S'^-* should be given 
each day. It should be borne in mind that the use of this 
drug is not unattended by danger, and inhalations of am- 
monia or the administration of a stimulant may be neces- 
sary during the sweating stage to maintain the heart's 
action. 

Quinin, in small doses three times a day, is recommended 
by some authorities, the statement being that its use at first 
increases the disagreeable symptoms, but is followed by their 
amelioration. 



DISEASES 01' 77/K PERCEPTIVE APPARATUS 493 

Primary acute labyrinthitis has been described by Politzer 
and Voltorini, but the disease is very rare. 

Panotitis, as the result of scarlatina, diphtheria, or variola, is 
not so very uncommon. The affection, which generally 
begins as an acute inflammation of the middle ear, extends 
to the labyrinth or both parts of the ear may be attacked 
simultaneously. The course of the disease is very rapid 
and it ends in complete destruction of the organ of hearing. 
Its sequelae maybe caries of the bone and chronic suppura- 
tion of the middle ear. 

Symptoins. — There is high fever, eclampsia, delirium, and 
sometimes loss of consciousness lasting for days. There is 
severe tinnitus and vertigo if the patient attempts to raise 
the head from the bed. A profuse discharge of pus pours 
from the meatus. Deafness is soon complete. 

Treatment. — As the disease is generally the result of in- 
fection in scarlet fever, diphtheria, or variola, the internal 
treatment is that suitable to these diseases. Should the 
patient's condition admit, pilocarpin may be given hypoder- 
mically or by the mouth. The middle ear should be 
cleansed twice a day by syringing with corrosive subhmate 
(i : 1000), the ear dried, and powdered boric acid and ace- 
tanilid (equal parts) insufflated by means of the powder- 
blower. 



FORMULAS 



DETERGENT WASHES AND REMEDIES USED TO 
CLEANSE MUCOUS MEMBRANES 

1. R Sodii bicarbonatis, 

Sodii biboratis, aa ^] ; 

Acidi carbolici, .^ss ; 

Glycerini, i^] ; 

Aquje, q. s. ad. f^iv. — M. 

Sig. Add to I quart of water and use as a wash. 

This is a modification of the celebrated '' Dobell's solution," 
and is entirely bland and iinirritating to mucous membranes. It 
may be used either as a spray to cleanse the mucous membrane 
of the nose, throat, and larynx or may be prescribed as a wash 
for the patient's use at home. When used as a nose- wash by the 
patient it should be at a temperature of about ioo° F. 

2. R Sodii bicarbonatis, 

Sodii biboratis, da ^j ; 
Sodii salicylatis, gr. iij ; 

Menthol, 

Thymol, da gr. i ; 
Glycerini, f ^j ; 

Aquae torridi, ^n^^- — ^^• 

Sig. Add enough water to make I quart and use with an atomizer or as a 
nose-wash. 

This formula yields a wash nearly as unirritating as Dobell's 
solution, and it has not the objectionable odor of carbolic acid. 
The concentrated wash is sufficiently antiseptic to preserve small 
anatomic specimens indefinitely, and the diluted wash w^ill pre- 
serve them for a considerable length of time. The solid ingre- 
dients of the wash may be compressed into a tablet of such size 
that one added to 4 tablespoonfuls of water will make a w^ash of 
the requisite concentration. Under such circumstances borax 
should be substituted for the glycerin of the formula in sufficient 
quantity to yield a wash of a specific gravity of 1020, because a 
wash of a much greater or less specific gravity than 1020 is more 
or less irritating to the nasal mucous membrane. These tablets 
494 



REMEDIES USED TO CLEANSE MUCOUS MEMBRANES 495 

produce a solution less irritating than the well-known Seller 
tablets and do not become so hard with age. 

Both Dobell's sohition and the wash, the formula of which 
is given above, should be comi)ounded at least three or four days 
before being used. During this time carbonic acid gas escapes, 
and glyceroles and other compounds are formed that render the 
solutions much more bland and unirritating to the nasal mucous 
membrane. For this reason it is sometimes convenient to pre- 
scribe one of the following proprietary preparations : 

3. H Listeria, f^iii-vj ; 

Aqua?, Oij. — M. 

According to the manufacturers listerin is the essential antisep- 
tic constituent of thyme, eucalyptus, baptisia, gaultheria, and 
mentha arvensis. of each i part ; especially prepared boric 
acid, 29 parts ; benzoic acid, i part ; rectified spirits, 250 parts; 
water, to make 1000 parts. 

It is one of the oldest and best known of the proprietary 
mouth-washes and gargles, and has been extensively used as a 
spray or douche for the nose. As an antiseptic a 25 per cent, 
solution of listerin in water is more than equivalent to a 5 per 
cent, solution of carbolic acid and is infinitely more pleasant to 
taste and smell, and is said to be non-toxic to the extent that 
listerin may be taken internally in teaspoonful doses three or 
more times a day. Hence twenty years ago attempts were made 
to substitute listerin, or what were supposed to be its active organic 
antiseptics, for the carbolic acid of Dobell's solution. Seiler's 
wash and tablets are attempts of this nature. Unfortunately lis- 
terin, instead of being a sedative to mucous membranes, is an 
irritant, and hence Seiler's wash is devoid of the sedative effects 
of the older Dobell's solution. Diluted listerin is acid in re- 
action and somewhat irritating to mucous membranes, and hence 
better adapted as a spray or wash to atrophic than hyperthropic 
rhinitis. 

4. H Alphasol. 

Sig. Dilute with 3 parts of water and use with an atomizer as a spray for 
the nose. 

5. H Glycothymolin. 

Sig. Dihite with 3 parts of water and use with an atomizer as a spray for 
the nose. 

6. H Lythol. 

Sig. Dilute with 5 parts of water and use with an atomizer as a spray for 
the nose and throat. 



4g6 DISEASES OF THE NOSE, THROAT, AND EAR 

7. R Thymozone. 

Sig. Dilute with an equal amount of water and use with an atomizer as a 
spray for the nose and throat. 

8. R Alkalol. 

Sig. Dilute with an equal amount of water and use with an atomizer as a 
spray for the nose and throat. 

9. R Borolyptol. 

Sig. Dilute with 10 parts of water and use with an atomizer as a spray 
for the nose and throat. 

10. U Euzone. 

Sig. Dilute with 4 parts of water and use as a spray for the nose. 

The last eight formulas are a few of the numerous pro- 
prietary preparations manufactured for use as nose- and throat- 
waslies. They are evidently elegant preparations as far as taste 
and smell are concerned, and under certain conditions it might 
be convenient to prescribe them. 

11. R Hydrogen dioxid. 

Commercial peroxid of hydrogen is sold usually as a 3 per 
cent., equal to a 15 -volume, solution of the gas. Its strength 
can readily be increased by evaporating the solution in a shallow 
vessel at a temperature considerably below the boiling-point, as 
under such circumstances the evaporation is much more rapid 
than the decomposition of the solution, and a strength of 100 
volumes or even more is readily obtained. The stronger solu- 
tions are caustics, quickly destroying living tissue. The ordinary 
1 5 -volume solution is very irritating to the mucous membrane of 
the nose and pharynx and, therefore, it should not be prescribed 
indiscriminately in catarrhal affections as a spray or gargle. 

Its chief use in rhinology and otology is for the removal of 
pseudomembranes, the cleansing of pus-cavities, and as a hemo- 
static, but when used for any of these purposes its irritating 
qualities should be borne in mind. 

When brought into contact with organic substances peroxid of 
hydrogen is decomposed with the liberation of nascent oxygen, 
which unites with the organic substance, often greatly increasing 
its bulk. When applied to a pseudomembrane in the pharynx 
the membrane is not only softened and decomposed, but its in- 
crease in bulk greatly facilitates its removal. For the removal 
of pseudomembranes the peroxid is best applied by means of a 
swab, made by wrapping cotton about the end of an applicator. 
In this manner the peroxid may be not only rubbed into the 
pseudomembrane, but the rubbing assists in detaching it from 
the mucous membrane. Of course the ''rubbing" should be 



REMEDIES USED TO CLEANSE MUCOUS MEMBRANES /^(^J 

done with judgment and gentleness, and it is rarely necessary to 
use a solution stronger than 3 per cent. The action of the 
swab may be assisted, if necessary, by spraying the membrane, 
if desirable, by means of an atomizer. 

For cleansing the middle ear, the antra of Highmore, or other 
cavities of pus, 3 per cent, peroxid, diluted with i or 2 parts of 
water, is generally sufficiently strong. Care should be used in 
injecting peroxid into a cavity that there is an opening sufficiently 
large to permit the easy escape of the gases generated by the 
decomposition of the peroxid. Should this not be the case, the 
pressure generated may be sufficient to cause great pain and, in 
the case of the middle ear, syncope and vertigo. In fact it is 
injudicious to inject peroxid through a small opening in the 
drum- head or a narrow sinus leading upward into the attic and 
mastoid antrum. It is stated that in the attic peroxid is capable 
of doing more harm than good by carrying pus into localities 
previously unaffected during its ebullition and thus spreading the 
infection. In the antra of Highmore peroxid is very valuable 
in loosening and disintegrating masses of adherent mucopus, and 
it is judicious to use at least one syringeful of diluted peroxid 
when cleansing that cavity. 

As a hemostatic peroxid acts by causing an immediate clotting 
of the blood with which it is brought into contact, and the clot 
formed under such circumstances is very bulky and firm. When 
pledgets of cotton soaked in peroxid are inserted into a bleeding 
nostril the blood coming into contact with the peroxid is im- 
mediately clotted, and until the peroxid is exhausted the more 
bleeding the more clotting, and consequently the more pressure 
upon the bleeding vessel. Remedies like adrenalin, that cause 
contraction of the blood-vessels, are generally of little use for 
controlling nasal hemorrhage, because the flow of blood prevents 
them from coming into contact with the nasal mucous membrane 
and producing any effects. 

12. R Caroid. 

Caroid is a bland, unirritating, powdered extract of the Carica 
papaya plant. It readily digests or dissolves sm^all sequestra, 
cheesy pus, cholesteatomatous scales, and pseudomembranes, etc. 
It may be used as a dusting-powder w^ithin the tympanum or as a 
solvent in necrosis. 

13. R Enzymol. 

Enzymol is a purified solution of pepsin prepared for external 
use. It is bland and unirritating and can be used freely within 
32 



DISEASES OF THE NOSE, THROAT, AND EAR 

the ear. It is especially useful in bringing about a cure of sinuses 
in the mastoid bone. For this purpose the sinus is first cleansed 
by syringing with sublimate solution, after which enzymol is in- 
jected and allowed to remain. The injections are made at inter- 
vals of twenty-four hours, and sometimes only three or four such 
injections are required to bring about the closure of a sinus that 
may have been discharging for months. Enzymol may also be 
injected by means of Blake's cannula into the vault of the tym- 
panum in the expectation of digesting and dissolving any choles- 
teatomatous masses or necrosed bone that may exist there, or the 
solution may be used at home by the patient. He should, after 
getting into bed, lie on his side, with the diseased ear uppermost, 
and fill its canal with enzymol. The fluid should remain in the 
ear as long as possible, as prolonged contact with morbid material 
is required in order to secure its digestion or solution. Neither 
enzymol nor caroid has any effect upon living tissues. In this 
respect they are, of course, similar in action to gastric juice. 

PROTECTIVES 

14. R Fluid albolene. 

Many of the bleached or white fluid cosmolins or vaselins for 
sale in the market are bland and unirritating, while others are 
very irritating to sensitive mucous membranes. The surgeon 
should assure himself of the bland and unirritating qualities of 
such preparations before using them in his office practice or pre- 
scribing them for the use of his patients. Certain gums and 
camphors nearly insoluble in water may be dissolved in fluid 
vaselin or albolene and used with advantage as applications to 
mucous membranes. Probably the most useful of such substances 
are menthol and camphor. 

15. H Fluid albolene, ^j ; 

Camphor, gr. x. — M. 

Sig. Use with an atomizer. 

The above solution of camphor in albolene is sedative and 
slightly astringent. 

16. H Fluid albolene, ^^j ; 

Menthol, gr. x. — M. 

Sig. Use with an atomizer. 

A solution of menthol in oil of the above strength, when 
applied to the nasal mucous membrane, produces at first a sensa- 
tion of irritation, followed by decided sedative effects and a sen- 



LOCAL ANESTIIKTLCS AND ANALGESICS 499 

sation of cold. Its analgesic pro})citics in acute coryza are 
decided. Frontal headache as a result of a cold in the head is 
promptly relieved by spraying the nasal mucous membrane with 
the above formula. 

A useful formula as a ])rotective to the nasal mucous memV)rane 
and for injection through a catheter into the middle ear is the 
following : 

17. H Menthol, gr. v ; 

Camphor, gr. xx ; 

Albolene, f^ij. — M. 
Sig. Use with an atomizer. 

To the above i or 2 drops of oil of eucalyptus, oil of pine, or 
oil of cinnamon may be added. 

Benzoinol is a proprietary preparation, said to be a solution of 
gum benzoin in albolene. 



LOCAL ANESTHETICS AND ANALGESICS 

18. U Solution of the hydrochlorate of cocain, 4 i)er cent. 

19. li Solution of the hydrochlorate of cocain, lo per cent. 

The local anesthesia produced by the apj^lication of a 4 per 
cent, solution of cocain to the nasal mucous membrane, although 
later in making its appearance, is more profound and enduring 
than if a stronger solution were employed. This is probably due 
to the fact that contraction of the superficial blood-vessels occur- 
ring almost immediately after the application of a strong solution 
of cocain interferes greatly with its further and deeper absorp- 
tion. For the removal of a large septal spur or the correction 
of a deviated septum a 4 per cent, solution of cocain should 
remain in contact with the parts for half an hour just previous to 
operating. The line of the saw-cut may be painted lightly with 
a 10 per cent, or stronger solution of cocain and the naris 
sprayed with adrenalin solution (i : 1000). The solution of 
cocain should not be used with an atomizer for the purpose of 
producing anesthesia of the nasal mucous membrane, as it is lia- 
ble to find its way into the pharynx and produce a most disagree- 
able sensation, the throat " feeling as if it were full of cotton," 
or some of the solution might even be swallowed and produce an 
untoward constitutional effect. When it is desired to produce 
local anesthesia of any portion of the interior of the nose for the 
purpose of a short operation, like the removal of a small septal 
spur or a cauterization, the removal of polypi, etc., a piece of 



500 DISEASES OF THE NOSE, THROAT, AND EAR 

absorbent cotton should be saturated with the cocain solution 
and laid in contact with that part of the nose where the anesthe- 
sia is desired, and, after the lapse of a few moments, the sensi- 
bility of the parts tested with a probe, and, if anesthesia has not 
been produced, the piece of absorbent cotton should be again 
dipped in the solution of cocain and replaced within the nose. 
'Practically a bloodless operation can usually be secured by then 
spraying the parts with a solution of adrenalin hydrochlorid 
(i : looo). 

Various formulas containing cocain have been advocated from 
time to time as being more reliable for local anesthesia than a 
simple solution of cocain. However, none of them are exten- 
sively used by the profession. Both chloral and carbolic acid 
have some value as local anesthetics to mucous membranes, and 
the following formula has the advantage over a solution of cocain 
that it does not as rapidly deteriorate, because both carbolic acid 
and chloral are antiseptics. Its anesthetic effects in the nose are 
about equivalent to a 3 per cent, solution of cocain and appear 
very rapidly : 

20. li Cocain, gr. xiij ; 

Chloral hydratis, gr. viij ; 

Acidi carbolici, gr. vj ; 

Aquae destil., fjj. — M. 
Sig. For use in the nose as a local anesthetic. 

Anesthesia of the larynx should be produced by throwing a fine 
spray of a 10 per cent, cocain solution upon the laryngeal mucous 
membrane, and repeating the procedure after an interval of two 
or three minutes. The sensibility of the lar\nix should then be 
tested with a cotton-tipped applicator dipped in a 10 per cent, 
solution of cocain from time to time, until the applicator can be 
moved about freely in the larynx without producing a reflex spasm, 
as there is little use in beginning an operation on the larynx 
when every touch of an instrument is followed by spasm or retch- 
ing and gagging. Anesthesia of the larynx, produced by the 
application of a solution of cocain, appears quickly after the 
application and lasts only a short time. Apparently cocain can 
be used more freely in the larynx than in either the nose or ear 
without danger of poisonous effects. 

Watery solutions are not absorbed with sufficient facility by 
the skin to render their use inside the auditory canal at all 
satisfactory for producing local anesthesia. Diminished sensi- 
bility of the drum-head and of the walls of the canal may, 
however, be secured by rubbing well into the skin a 10 per 



LOCAL ANESriIEriCS AND ANALGESICS 5OI 

cent, ointmenl of cocainin /^;//^////, and this ointment is probably- 
better than preparations of morphin, atropin, etc., for the rehef 
of the pain of otalgia. When prescribed for this purpose it 
should not, of course, be rubbed into the skin of the canal, but 
simply inserted within the meatus, due care being exercised when 
the drum-head is absent not to use a sufficient quantity to pro- 
duce a poisonous effect. When the drum-head is present the 
ointment will remain for days in contact with it and be slowly 
absorbed. Its sedative effects are, under such circumstances, 
followed by no reaction. 

For the production of local anesthesia for the removal of aii?'al 
polypi a pledget of cotton saturated with a 4 per cent, solution 
may be allowed to remain for five minutes in contact with the 
parts. This method, however, is not adequate for the production 
of local anesthesia in removal of the ossicles or, in fact, any of 
the more painful and tedious intratympanic operations, which or- 
dinarily necessitate the almost complete local anesthesia resulting 
from the subcutaneous injection of equal amounts of a i per 
cent, solution of cocain and a i : 1000 solution of adrenalin 
in several places beneath the skin of the canal at the junction of 
the bony and cartilaginous portions. An ordinary hypodermic 
syringe with a small needle about 2 inches long, reinforced to 
within 1 inch of its point, is convenient for the injections ; 10 or 
even 20 minims may be required to produce complete anesthesia 
of the middle ear. According toBallin, who first described this 
method, the fluid should be injected beneath the skin at the upper 
portion of the canal at the junction of the cartilaginous and bony 
parts. Within a few moments after the injection anesthesia of 
the middle ear is so complete that the removal of the malleus 
and incus and the remains of the membrana tympani can be 
accomplished often bloodlessly and with scarcely more pain than 
would result from intratympanic syringing. 

Eucain, alypin, stovain, and several other substances have been 
offered as substitutes for cocain, the claim being that they possess 
anesthetic qualities similar to those of cocain and are less liable 
to produce toxic effects. 

In cases that are known to be sensitive to the toxic effects of 
cocain it would be well to employ one of these substances. 
Alypin may be employed successfully in a 10 per cent, solution 
in the same manner as a 4 per cent, solution of cocain. It does 
not, like cocain, produce a contraction of the blood-vessels of 
the nasal mucous membrane. According to Dr. Tapia, of Madrid, 
stovain, which should be used in the same strength as cocain, is 
far less toxic and because of its diuretic properties is quickly 



502 DISEASES OF THE NOSE, THROAT, AND EAR 

eliminated from the system. The fact that neither alypin nor 
stovain contract the tissues renders them valuable anesthetics 
in operations upon posterior nasal hypertrophies. 

Two varieties of eucain are dispensed — alpha and beta. The 
latter is claimed to be three and three-fourths times less toxic 
than the former. Beta-eucain is employed as an anesthetic in 
about the same strength of solution as cocain. 

HEMOSTATICS 

21. R Adrenalin hydrochloratis, i : looo. 

The active blood-pressure-raising principle obtained from the 
suprarenal capsule of beeves or sheep is variously designated by 
manufacturers, probably for commercial reasons. For example, 
supra7'enalin and adnephrin are apparently the same as adrenalin. 
The substance is usually sold in i : looo solution, containing 2^ 
of I per cent, of methaform or some other antiseptic to prevent 
the decomposition of the adrenalin, which somewhat rapidly 
occurs when the solution is diluted. For this reason adrenalin is 
prepared by some manufacturers in tablets, one of which dissolved 
in 15 minims of water yields a i : 1000 solution. The solutions 
prepared by dissolving one of the tablets contains no antiseptic 
to irritate the nose, and for this reason is somewhat better in the 
treatment of hay-fever and other conditions where the nasal 
mucous membrane is irritable. In the same class of cases adre- 
nalin dissolved in albolene or an ointment of adrenalin yields 
better results than a watery solution. 

Locally adrenalin solution may be used as a spray or applied 
by means of absorbent cotton. For the relief of local con- 
gestions a I : 5000 or even i : 20,000 solution yields good results. 
To produce local ischemia in mucous membranes preparatory to 
a surgical operation a i : 1000 solution is generally employed. 

The best results are obtained by applying pledgets of cotton 
■saturated with a 4 per cent, solution of cocain to the field of 
operation within the nose and after half an hour spraying the 
parts with adrenalin solution (i : 1000). If after a moment or so 
the parts are not sufficiently blanched, more of the spray should 
be used. 

When used in this manner small exostoses can often be sawed 
from the nasal septum without the loss of a drop of blood unless 
a vessel of considerable size be encountered. However, sec- 
ondary Jiemo7'r]iage occurring one or two hours after a nasal opera- 
tion is said to be more common when adrenalin has been em- 



HEM OS TA TICS 503 

ployed, because the ischemia of mucous membranes produced 
by adrenahn applications is apparently followed by congestion 
when the effects of the drug have passed off. 

The fact that applications of adrenalin to the nasal mucous 
membrane are followed by congestion as soon as the effects of 
the drug have passed i)revents the remedy being entirely satis- 
factory in the treatment of hay-fever. The best results are ob- 
tained by somewhat frequent api)lications, say once in two or 
three hours, of a solution not stronger than i : 5000 or 10,000 or 
one of the oily preparations of adrenalin. However, in spite of 
every precaution, after a few days the condition of a hay-fever 
patient using local applications of adrenalin is in nowise im- 
proved, and is usually worse, because the remedy is in no sense 
curative. At best it gives only temporary relief. 

The /d^w^/^r^-^/ suprarenal gland is sometimes given internally 
in doses of 2 to 5 gr. three or four times a day in the treatment 
of hay-fever, or 5 to 30 minims of a i : 1000 solution of adre- 
nalin may be given as often as every two hours in hemoptysis 
and hemophilia. 

When given internally the effect of adrenalin upon the heart 
should be borne in mind and watched with a certnin amount of 
caution, although no more serious results than headaches and 
dizziness are likely to occur from its prolonged use in consider- 
able doses. 

The effects of adrenalin on the heart are similar to those of 
digitalis, with the difference that it acts with greater rapidity, its 
effects are not as prolonged, and the blood-pressure-raising effect 
is more apparent. It slows the pulse and strengthens the cardiac 
systole while it shortens and renders diastole less perfect. It is a 
valuable cardiac stimulant and may be used hypodermically in 
heart failure during chloroform anesthesia. 

Adrenalin is usually classed among the alkaloids, because it is 
a nitrogenous compound forming salts with acids. It probably 
exists in the suprarenal capsules in combination with some organic 
acid. It is decomposed by prolonged contact with alkalies and, 
therefore, should not be prescribed in conjunction with an alka- 
line nose-wash. It is a reducing agent and, therefore, should not 
be used in conjunction with hydrogen dioxid, permanganate, etc. 
It attacks many metals, tarnishing them and producing a black 
precipitate, therefore adrenalin solutions should not be allow^ed 
to remain for any great length of time in atomizers with metal 
tubes- 

In nasal hemorrhage Mulford injects 10 drops of a i : 2000 
solution of adrenalin into the middle of the upper lip of the 



504 DISEASES OE THE iVOSE, THROAT, AND EAR 

same side as the bleeding nostril. He reports 3 very severe 
cases of epistaxis promptly controlled by this method. 

22. 5t Acidi tannici, 

Acidi gallici, da gr. xx. — M. 

Sig. Add to a tumblerful of water and slowly sip the mixture. 

Useful in controlling oozing of blood from the wound after 
amputation of the tonsil. 



HEMOPTYSIS. EPISTAXIS 

23. R Ergotin. (aq. ext.), 3J ; 

Ext. hyoscy. ale, gr. iij. — M. 

Ft. cap. No. XX. 
Sig. I eveiy three hours. 

24. U Acidi gallici, 

Spts. rectif., 
Glyceriui, 
Sig. I teaspooonful every two hours. 

25. R Plumbi acet., gr. xxiv ; 

Pulv. opii, gr. xij. — M. 

Ft. chart. No. xii. 
Sig. I every four hours. 

■ 26. R 01. terebinth., |j ; 

Muc. acaciae, ^^iij ; 

01. gaultherise, |||ij._M. 
Sig. I teaspoonful every hour with water. 

27. R Liq. ferri persulph., 

Glycerini, ad ^ss. — M. 

Sig. 10 drops every hour if necessary. 

28. R Calcii chloridi, gr. xl. — M. 
Ft. cap. No. viii. 

Sig. I every hour until the bleeding is controlled. 

The investigations of A. E. Wright seem to prove that the 
effect of calcium chlorid is to increase the coagulability of the 
blood, but if too large a quantity of the drug is given the oppo- 
site result is caused, namely, diminished coagulability. On this 
theory 2 or even 3 capsules (10 to 15 gr.) may be given at inter- 
vals of an hour in severe cases, but the amount of 80 gr. should 
not be exceeded in as many hours. Even in cases where the 
hemorrhage has not been completely controlled, if 80 gr. have 
been given within eighty hours, it is best to wait several hours be- 
fore again resorting to the drug. 



LOCAL SEDATIVES 505 



LOCAL SEDATIVES 




IJ Antipyiin, 
A(iiuc', 


gr. x-xxx 
f3J.-M. 



29. 

A solution of antipyrin of 2 to 4 per cent, strength, when 
sprayed upon the mucous membrane of the nose or pharynx, has 
the power of contracting the capillaries and of producing an 
artificial anemia, which effect is maintained for from three to five 
hours. Solutions of antipyrin may be used with the atomizer in 
all acute inflammations of the mucous membrane of the upper 
respiratory tract. When used after the application of cocain to 
the interior of the nose a 4 per cent, solution will maintain the 
contractile effect of cocain upon the erectile tissue for several 
hours. When sprayed upon the nasal mucous membrane without 
the previous application of cocain a 4 per cent, solution gives 
rise to a smarting sensation, which, however, quickly subsides. 
Antipyrin solutions of the proper concentration applied to 
mucous membranes produce analgesia, but not local anesthesia. 

30. R Antipyrin, ^i-iij '■> 

Aquoe, q. s. f^ij. — M. 

This formula is extremely useful as a daily application to the 
larynx in all forms of laryngeal inflammation. A brush or a 
dossil of absorbent cotton wrapped about a bent probe should be 
saturated with the solution and applied to the glottis. The appli- 
cation of antipyrin solutions of the strength of 50 per cent, and 
upward produces a burning sensation, quickly followed by a sen- 
sation of relief and comfort. Applied in this manner to the 
larynx antipyrin is not an anesthetic, but an analgesic whose 
effects persist for several hours. In the strength of 5 to 10 per 
cent, solutions antipyrin is superior as an antiseptic to Van Swie- 
ten's liquid. In therapeutic doses antipyrin acts as an antispas- 
modic, diminishing the reflex excitomotor power of the spinal 
cord, and also as an analgesic, relieving the pain of neuralgia 
and migraine, whether due to reflex nasal irritation or to some 
other cause. Applications of strong solutions of antipyrin to 
the larynx should be supplemented by the patient inhaling five or 
six times a day the spray from an atomizer containing a 4 per 
cent, solution. The effects of antipyrin upon the heart should, 
of course, be borne in mind and the patient, if weak, should be 
cautioned not to swallow any portion of the spray deposited in 
the mouth, and not to use too large a quantity of the solution at 
one time, although in a 4 per cent, solution there is in i ounce 
only about 20 gr. of antipyrin, and much more than this amount 



506 DISEASES OF THE NOSE, THROAT, AND EAR 

in twenty-four hours probably could be used with impunity by 
most patients. 

31. R Atropise sulphatis, gr. iv ; 

Morphife sulphatis, ^^j ; 

Aquae, f^j. — M. 

One or two drops may be applied inside the auditory canal for 
relief of the pain incident to acute inflammation of the middle 
ear and myringitis. 



3-- 
Sig. 


R lodoformi, 
Ether, 
Use as a spray for the larynx. 

PIGMENTS 


gr. Ix ; 
|ij.— M. 


■hi- 


R lodini, 

Potassii iodidi, 
Glyceriiii, 


gr. v; 
gr. XV ; 
f^j._M. 


34- 


Boroglycerid, 50 per cent. 




35- 


R Acidi tannic], 
Glycerini, 


gr. xl; 
f5J.-M. 



Formula 35 is an excellent application to the nasopharynx in 
the postnasal catarrh of adults. In children, Formula ^iZ gen- 
erally yields better results. 

Formulas 33-35 may be used in the treatment of chronic 
and hypertrophic rhinitis. The effects of the applications vary 
with the amount of the solution used. No more of the iodin 
solution should be applied at one time than will produce a 
momentary sensation of discomfort. Applied inside the crypts 
of the tonsils by means of a cotton-tipped probe bent at a right 
angle it often brings about a rapid absorption of the hypertrophied 
glands. Either of the solutions may be applied by means of 
a suitable cotton-tipped probe to the mucous membrane of the 
nose or nasopharynx. 

36. R Lignol, 

Oleum olivae, da f^j. — M. 

Lignol is an oily or tarry substance resulting from the dis- 
tillation of a special lignite. It is soluble in ether and oils, but 
not in water. It contains phenol, guaiacol, xylenol, etc., prob- 
ably combined with pyridin bases. It has antiseptic properties 
equivalent to a i : 1000 bichlorid solution, and when properly 
diluted is not irritating to mucous membranes. It is a useful 



OfNTMRNTS 50/ 

application in atrophic rhinitis, dihitcd with an c(|ual amount of 
sweet oil or albolene. 

Z1- U Petroleum, gm. 43.00 ; 

Olei eucalypti odoris citri, gm. 0.50 ; 

Strychni;t nitratis, gm. 0.02. — M. 

T. liobone. 
Useful as a pigment in atrophic rhinitis. 

OINTMENTS 

38. li Ichthyol, ^ij ; 

Adeps lance, 

Pelrolati, ad f^y — M. 

Useful as an inunction over the mastoid in commencing mas- 
toiditis, and as an inunction over hypertrophied lymphatic 
glands in the neck. 

39. R Unguenti hydrargyri, 

Unguenti iodini, aa ^]. — M. 

Useful as an inunction over the mastoid in commencing mas- 
toiditis, and as an inunction over hypertrophic lymphtic glands 
about the angle of the jaw. 

40. li Unguenti hydraigyri, 

Unguenti iodini, 

Unguenti belladonnse, dd ^j. — M. 

Useful as an inunction within the auditory canal in furunculous 
and diffuse inflammation. 

41. U Hydrargyri oxidi flavi, gr. vj ; 

Olei petrolati, q. s. 

Petrolati, 5J. — M. 

Useful as an application in eczema of the auricle after all scabs 
and crusts have been removed by means of peroxid of hydrogen. 
This ointment should be well rubbed into the inflamed tissues, 
and a single application is sometimes sufficient to bring about a 
cure if care be exercised that purulent discharges from the tym- 
panum are not allowed to come into contact with the skin of the 
auricle. 

42. R Plumbi iodidi, gr. xlv ; 

Ammon. chloridi, gr. xlv ; 

Ichthyol, ^] ; 

Adeps lanae, q. s. ad. ^j. — M. 

Ft. unguentum. 
Sig. External use in glandular inflammations. 



5o8 DISEASES OF THE NOSE, THROAT, AND EAR 

43. R Cocain hydrochloridi, gr. xij ; 

Adeps lanae, ^ij, — M. 

Useful in relieving the pain of subacute catarrh of the middle 
ear, furunculosis, etc. An ointment penetrates the skin of the 
canal more readily than a watery solution. For the relief of the 
pain of aural neuralgia or acute catarrh the ointment is simply 
placed as deeply within the canal as possible. For the relief of 
the pain of furunculosis the ointment is smeared upon a cone of 
cotton, which is wedged into the meatus with as much pressure 
as the patient conveniently can bear. The pressure, at first pain- 
ful, ultimately relieves congestion and discomfort. 

CAUSTICS 

With the exception of the galvanocautery the caustics most em- 
ployed in rhinology and otology are chromic and trichloracetic 
acids. As the destruction of tissue produced by applications of 
even the solid stick of nitrate of silver is very superficial, it 
scarcely can be considered a caustic. 

ASTRINGENTS 

44. B Zinci sulphatis, gr. x-xx ; 

AquDe, f^j.— M. 

Useful as an application by means of a brush or a dossil of ab- 
sorbent cotton to the pharynx and larynx in subacute and chronic 
laryngitis, and to the nasopharynx in subacute nasopharyngeal 
catarrh. 

45. K Tinctura ferri chloridi, 

Glycerini, ad f^ss.— M. 

Useful as an application to erosions over varicose vessels in 
chronic nosebleed. 

46. R Acidi gallici, gr. v-x ; 

Petrolati, SJ-— M. 

Sig. For patient's use in recurrent nasal hemorrhage and in the chronic 

rhinitis of children. A piece the size of a pea should be inserted in each 
nostril night and morning. 

47. R Pil. atropiae sulphatis, gr. ■^^-^. 
Sig. I every three or four hours. 

Useful in controlling excessive nasal secretion in coryza, hay- 
fever, and nasal hydrorrhea. 



ASTRINGENTS 509 

48. K: Atropia: sulphatis, gr. ss-iss ; 

At[UCE destil., fjij. — M. 

Sig. Use with an atomizer every two hours. 

Useftil in nasal hydrorrhea. The patient should be informed 
that the solution is highly poisonous, and cautioned against using 
a larger quantity than sufficient to barely moisten the nasal mu- 
cous membrane each time the atomizer is used. 

49. li Alcohol, 95 per cent. 

Useful as an application to the tympanic mucous membrane 
when it is covered by granulations and small polypi. For the 
patient's use at home, to cause shrinking of granulations and 
polypi, alcohol, diluted with an equal amount of water, may be 
prescribed, to be dropped into the auditory canal several times a 
day. Should this cause only momentary smarting, the patient 
should on the next occasion use alcohol 2 parts diluted with water 
I part, and so on until undiluted 95 per cent, alcohol is dropped 
into the ear four or five times a day. Practically the ear will 
then contain alcohol all the time. It acts as a dehydrating agent 
on polypi and exuberant granulations, destroying their vitality 
and promoting cicatrization. Its value as an antiseptic also plays 
its part in bringing about a good result. Boric acid dissolved 
in the alcohol is sometimes prescribed for the patient's use, but, as 
under such circumstances when the alcohol evaporates the 
boric acid is deposited as sharp-pointed crystals on the mucous 
membrane, it is probable that the boric acid is a source of irri- 
tation. The same may be said to a less degree of the addition to 
the alcohol of other dehydrating agents like glycerin and sulphuric 
ether. In order to secure the best results from instillations of 
alcohol the patient should lie down with the affected ear upper- 
most and then straighten the canal upward, outward, and back- 
ward. The canal should then be filled with alcohol, which 
should be forced into the tympanum by manipulating the tragus. 
This procedure also serves to float outward particles of pus and 
other materials. Polypi of considerable size may be destroyed by 
this method, but it is somewhat tedious if the polypi are large, and 
hence such growths should be removed by snare or forceps. 

50. R Argenti nitratis, gr. x-^ij ; 

Aquae, f^j. — M. 

Silver nitrate (3J to i ounce of water) is useful as an applica- 
tion to the pharynx or tonsils in acute pharyngitis or tonsillitis. 
When applied sufficiently early it will often abort the disease if 



5IO DISEASES OF THE NOSE, THROAT AND EAR 

used two or three times a day. When painted upon the lateral 
walls of the pharynx it produces at once a feeling of relief and 
comfort which persists for some time ; when painted upon the 
posterior wall of the pharynx, a sensation of dryness and great 
discomfort. Hence it should not be used in this portion of the 
pharynx except for touching small areas of granulation tissue, etc. 
However, lo-gr. solutions are permissible. 

Solutions of silver nitrate (60 gr.) also may be used as an 
astringent application to small polypi and exuberant granulation 
tissue in the tympanum. However, for this purpose it is far in- 
ferior to strong alcohol. Even the solid stick of silver nitrate 
when applied to granulations in the ear produces only a super- 
ficial destruction of tissue, and in this respect is far inferior to 
chromic or trichloracetic acids. 

51. R Protargol. 

52. H Argyrol. 

The above are two of the best of the organic compounds of 
silver. Of the two, argyrol is probably the more valuable in con- 
trolling inflammations of mucous membranes. Protargol may be 
used as a spray to the pharynx or larynx in 10 per cent, solutions 
and argyrol in 20 per cent, solutions. Both produce ugly stains 
on linen, but do not stain the skin. They stop up atomizer tubes 
somewhat quickly, and hence are not well adapted for patient's 
use at home. Protargol and argyrol, when applied to mucous 
membranes, are somewhat astringent antiseptics, are devoid of 
the irritating effects of silver nitrate, and penetrate the tissues 
more deeply. Argyrol in 10 per cent, solution is especially 
serviceable in the recurrent attacks of otorrhea where the drum- 
head has been destroyed. If applied at an early stage of the 
attack a single application by means of a cotton-tipped probe 
will usually abort the attack. It is valuable as a non-irritating 
antiseptic injection by means of Blake's cannula into the attic of 
the tympanum in attic otorrhea, often bringing about a cessation 
of the discharge. 

Purulent inflammation of the accessory sinuses of the nose may 
be treated by first cleansing them by injections of sterile water, 
peroxid of hydrogen, etc., and then injecting a small quantity of 
a 20 per cent, solution of argyrol, which is allowed to remain. 
The non-toxic and non-irritating properties of this antiseptic 
permits this being done with impunity. Under such circum- 
stances the discharges are stained brown and are rapidly changed 
in character from purulent to mucoid. 



D USTING- PO WDERS 5 1 1 



DUSTING-POWDERS 

53. li Menthol, gr. j; 

Sodii bicarb., gr, ij ; 

Magnesii carb. (l^^'vis), gr. iij ; 

Cocain hydroclikM., gr. iv ; 

Sacchari iaclis, ^iss. — M. 
Sig. Use as snuff every two or three hours. 

The most marked relief follows the use of this powder, and a 
itw applications will do much to abort acute rhinitis. Its effects 
are immediate, highly agreeable to the patient, and continue for 
a number of hours. The preparation should be dispensed in a 
tightly-corked vial to prevent evaporation of the menthol, and a 
pinch should be sniffed up into each nostril every two or three 
hours or sufficiently often to maintain the nose in a putulous con- 
dition and limit the secretions. As the result of the use of the 
snuff the patient remains practically free from all nasal symp- 
toms during the attack, and there is no danger of contracting the 
cocain-habit where the laws, as in Pennsylvania, forbid the refill- 
ing of a prescription containing cocain without the consent of 
the physician. 

54. H Argenti nitratis, gr. x ; 

Zinci stearatis, ^j. — M. 

55. H Argenti nitratis, gr. xx ; 

Zinci stearatis, ^ij. — M. 

Formulas 54 and 55 are useful in the treatment of atrophic 
rhinitis. Formula 54 should be applied with the powder-blower 
to the nasal mucous membrane as long as its use is followed by a 
moderate amount of smarting and increased nasal discharge. 
When this ceases to occur Formula 55 may be used. 

56. B; Zinci sulphatis, 

Sacchari lactis, dd ^\] ; 

Acacise, gr. x. — M. 

57. B Alumnol, ;5J ; 

Sacchari lactis, ^ij. — M. 

Useful as applications to the laryngeal mucous membrane in 
acute and chronic laryngitis. In cases in which bronchitis as 
well as laryngitis is present the powder should be applied during 
deep inspiration, in order that it may reach the trachea and 
bronchi. 



5 12 DISEASES OF THE NOSE, THROAT, AND EAR 

58. li lodoformis, gr. xxx ; 

Acidi tannici, ' gr. xx ; 

Sacchari lactis, gr. xxx. — M. 

Useful as an application in syphilitic and tuberculous laryn- 
gitis. 

59. R Bismuth, subnitratis, SU > 

Acacise, gr. x ; 

lodoformis, 5^ss ; 

Morphise sulphatis, gr. xx; 

Acidi tannici, gr. xxx. — M. 

Useful as an application to the laryngeal mucous membrane in 
tuberculous and syphilitic laryngitis, in the earlier stages of acute 
laryngitis, or in any laryngeal affection characterized by irrita- 
bility and pain. 

60. R Orthoform. 

This nearly insoluble substance has the property of producing 
analgesia when applied to exposed nerve-endings. It is, there- 
fore, especially valuable as an application to irritable ulcers after 
they have been cleansed with Dobell's solution or peroxid of 
hydrogen. Its anesthesic effects are increased by a previous 
application of a solution of cocain and persist for four or five 
hours. When insufflated into a tuberculous larynx the powder 
produces a momentary smarting, followed by analgesia more or 
less complete, which persists as long as the powder adheres to an 
abraded surface or an ulcer. The powder possesses decided anti- 
septic qualities and promotes the healing of tuberculous ulcera- 
tions. It has little effect upon the unbroken mucous membrane 
and its prolonged application to the skin in the neighborhood of 
ulcerations sometimes causes eczema, 

A nurse or one of the patient's friends can be taught to insufflate 
orthoform into a tuberculous larynx ten minutes before each meal, 
and in many instances thus secure complete relief from dysphagia. 
Orthoform is said to be non-toxic, and hence may be used locally 
in liberal quantities. 

61. R Pulvis acidi borici. 

It is absolutely necessary that the powdered boric acid, in- 
sufflated within the tympanum as an application in the treatment 
of purulent inflammation, should be impalpable and free from all 
grit, as the sharp-pointed crystals of this substance are extremely 
irritating. A good plan is to test the powdered boric acid by 
rubbing a small quantity upon the lip with the tip of a finger, 



D USTING-PO WDKkS 5 I 3 

rejecting as unfit for use inside the ear those specimens that are 
"gritty." 

It is important also that too large a quantity of boric acid 
should not be thrown into the ear at one time or it may form a 
hard mass and thus prevent the escape of discharges. This is 
less likely to occur if the powdered boric acid be triturated with 
tincture of calendula officinalis, as advised by Sexton. 

The following powders are of use in the treatment of otorrhea : 

62. B Chinolini salicylatis, 3ss-j ; 

Pulvis acidi boric!,- ^j. — M. 

Burnett. 

63. U Aluminii, gr. x ; 

Pulvis acidi borici, ^j. — M. 

64. R lodoformi, ;5J ; 

Pulvis acidi borici, ^j. — M. 

65. R Pyoktanin, 3J ; 

Acidi borici, 3^~E'i- — M. 

Sig. Use as a dusting-powder in otorrhea where the opening through the 
drum-head is sufficiently large to permit the entrance of the powder into 
the tympanum. 

Pyoktanin (J>us destroyer) or methyl-violet is an anilin dye 
occurring in the form of a paste and in crystals. It is said to 
penetrate the tissues and act upon deeply imbedded pathogenic 
micro-organisms. It has been used somewhat more extensively 
than at present in the treatment of otorrhea. The chief objec- 
tion to its use is the deep-blue stain imparted to the skin of the 
auricle by discharges containing pyoktanin when they escape 
from the canal. This stain, however, is somewhat readily re- 
moved by washing with alcohol. 

Solutions of pyoktanin of the strength of i : tooo or even 
I : 100 may be injected into the attic in chronic otorrhea after 
a preliminary cleansing with water and peroxid of hydrogen. 
Under such circumstances it penetrates somewhat deeply and is 
rapidly absorbed by any bacteria present. These are deeply 
stained and are said to be killed or at least rendered inert by the 
dye. Pyoktanin may also be used as a dusting-powder combined 
with boric acid, as in the above formula. 

The paste is sometimes molded into the form of pencils and 
used to rub into syphilitic ulcerations, etc. A variety of the 
drug is yellow, but is said not to be so active as the violet pyok- 
tanin. 

33 



514 DISEASES OE THE NOSE, THROAT, AND EAR 

Pyoktanin, when given internally in doses of 2 or 3 gr. three 
times a day, stains the urine a deep blue, and after the drug has 
been taken for two or three days the urine of such persons will 
remain aseptic for three weeks, even when exposed to the air in 
an open vessel. While pyoktanin undoubtedly possesses con- 
siderable value as a comparatively safe antiseptic, its usefulness 
has been greatly restricted, both in the treatment of otorrhea and 
in genito-urinary surgery, because of the objectionable blue 
stains w^hich it produces, 

66. H Acetanilid, ^ ^h 5 

Acidi borici, * ^j. — M. 

Sig. Use as a dusting-powder to infected or foul-smelling wounds after 
mastoid operations. 

Acetanilid, a derivative of anilin, is a white powder but 
slightly soluble in water and possessing decided antiseptic prop- 
erties. It is, either alone or diluted with boric acid powder, a 
somewhat popular hospital dressing for superficial wounds ' ' that 
are not doing well." It is especially useful in wounds after a 
mastoid operation where the discharges are foul smelling and the 
chiseled bone remains long uncovered by granulations. The 
powder, under such circumstances, should be thickly dusted into 
the wound. lodin is liberated when the substance is brought 
into contact with organic matter and acts as an antiseptic. 

67. R Nosophen. 

Sig. Use as a dusting-powder for the nose or middle ear. 

This compound, obtained by the action of iodin upon a solu- 
tion of phenolphthalein, is free from odor or taste and contains 
60 per cent, of iodin. It is free from irritating effects when 
applied to the mucous membrane of the nose or tympanum and 
may be used as a dusting-powder as a substitute for iodoform 
after operations in such localities. 

68. R Aristol (dithymol diiodid). 

Sig. Use as a dusting-powder for the nose or middle ear. 

Aristol is probably the most valuable of all the ''substi- 
tutes for iodoform," as it has a faint but agreeable smell some- 
what resembling thymol. It is used somewhat extensively as a 
dusting-powder to the wound after operations on the middle 
ear, nose, and pharynx to promote cicatrization. It is not 
irritating to the nasal mucous membrane. Aristol is a reddish- 
brown, amorphous powder, containing about 45 per cent, of 
iodin, which is slowly liberated into a wound dusted with this 
powder and packed with sterile gauze. 



AJ/IKRA riVES 515 

69. H lodoinulli. 

70. H Bismuth, .subiodidi. 

Either of the above are sometimes useful as dusting-powders in 
otorrhea where a sufficient amount of the drum-head has l^een 
destroyed to permit their being thrown upon the exposed mucous 
membrane of the tympanum. 

71. H Pulvcris ahimiiii compositoc. 

E. R. Squib >S: Sons. 

'rhe compound aUim powder of Squib is often useful in pro- 
moting early epidermization of the tympanum after the radical 
mastoid operation. 

72. Xeroform. 

H Bismuth oxid, 49 \)&x cent. 
Tribromphenol, 50 per cent. 

Xeroform or bismuth tribromphenol is an odorless synthetic 
product of the manufacturing chemists, and presumably has the 
sedative and astringent properties of bismuth combined with the 
marked antiseptic qualities of bromin and carbolic acid. As it 
has been given internally (5 to 7 gm. daily) by Hueppe, during 
the cholera epidemic at Hamburg, in 1893, with excellent results, 
it may be assumed that its local application to wounds and mucous 
membranes is absolutely devoid of danger of toxic effects. Upon 
wounded or inflamed mucous membranes it is an astringent, anal- 
gesic, and an antiseptic. 

Somers i^Neiu York Med. Jour., December 24, 1898) speaks 
with enthusiasm of the value of xeroform in aural practise. He 
has used it in more than 100 cases of chronic suppurative otitis 
media. It does not stain like pyoktanin or cake like boric acid, 
and it greatly modifies the character of the discharge from the 
middle ear. It promotes epithelial growth and cicatrization and 
relieves the annoying pruritus which tends to delay the repair of 
the tissues. 

ALTERATIVES 

73. R Hydrargyri bichloridi, gr. j ; 

Potassii iodidi, :^ij ; 

Aquee, fgiij. — M. 

Sig. I to 3 teaspoonfuls after meals. 

This formula, sometimes called '' i, 2, 3 mixture," may be 
ordered when it is desired to employ the mixed treatment in 
syphilis. 



5l6 DISEASES OF THE NOSE, THROAT, AND EAR 

74. ^ Tablet triturat. hydrarg. protiodidi, gr. \. 

Sig. I tablet may be taken three or four times a day or even oftener, with 
a sufficient quantity of opium, if necessary, to prevent diarrhea. 

Useful in the treatment of primary and secondary syphilis. 

75. R I'il- hydrarg. biniodidi, gr. jV-s- 
Sig. I pill may be taken after each meal. 

Useful in the treatment of the later stages of syphilis. 

76. IjL Hydrarg. bichlor., gr. iij ; 

Aqute deslil., l^j. — M. 

Sig. Corrosive sublimate solution for hypodermic use. 

m>^ = g'-- T6- mx"j = gj^- T2- m^v = gr. j^. i^xx = i 

Useful in syphilitic affections of the nose and throat where it 
is advisable to get the patient under the influence of mercury as 
speedily as possible. The injections may be made as often as 
once a day, deep into the cellular tissue of the back. The injec- 
tion causes a moderate amount of pain, which continues for about 
an hour, and the place where the injection was made remains a 
little sensitive to the touch for twenty to forty-eight hours ; ab- 
scess does not occur when the proportion of corrosive sublimate 
is not greater than in this formula. 

In a small proportion of cases mercury or iodid of potassium 
produce a violent reaction, the syphilitic lesions, for the time 
at least, being rendered worse instead of better by the exhi- 
bition of these drugs. Other cases, because of the disturbance 
of the gastro-intestinal tract, cannot tolerate either the iodids or 
mercury. Such cases generally do well on the following pre- 
scription : 

77. R Ext. berberis aquifolii, f^iv- 
Sig. 15 to 120 drops in water every three hours. 

The initial dose is 15 drops every three hours, increased 5 drops 
per week until the patient is taking 2 fluiddrams every three 
hours. The dose is then reduced each week until the initial dose 
of 15 drops is reached. This is continued for a week or two and 
again increased. 

78. R Tr. guaiac. ammoniati, f^j. 

Sig. \ teaspoonful in milk every three or four hours, gargle and swallow. 
See Formula 138. 

Useful in acute pharyngitis or tonsillitis of rheumatic origin. 





HYPNOTICS 


8o. 


K Trional, 


8i. 


li Sulphonal, 


82. 


R Paraldehyd., 
Olei gaultherioe, 
Pulveris acacioe, 




Elixir simplicis, 



HYPNOTICS 517 

79" R Potassii bromidi, ?ss ; 

Potassii iodidi, Tiss; 

Ext. glycyrrhizK, ^^iss ; 
Aquoe, q. s. ad. V^iv.— M. 
Sig. I teaspoonful three or four times a day. 

Useful in pharyngitis sicca, to increase the pharyngeal secre- 
tions arid relieve the feeling of dryness in the throat. 



gr. x-xxx. 
gr. x-xxx. 
f^ss; 

q. s. ad. f^iv. — M. 
Sig. \ to I tablespoonful in water every hour or two in the restlessness 
and insomnia following mastoid operations. 

83. JJ Chloral hydratis, gr. x; 

Codein sulpbatis, gr. \\ 

StrychnicE sulpbatis, gr. ^^. — M. 

Ft. cbartDe No. i. 
Sig. To relieve restlessness and insomnia after mastoid operations. Dis- 
solve in half-tumblerful of water and repeat dose in three hours if necessary. 

84. R Somnos, f^iij- 

Sig. 2 teaspoonfuls to I tablespoonful every hour or two, if necessary, to 
quiet restlessness and induce sleep after operations. 

After many severe operations on the nose, throat, or ear the 
patient for the first night or two will complain of pain, restless- 
ness, and inability to sleep. This is especially true in neglected 
mastoid cases that have been operated on only after weeks of 
needless suffering and consequent demoralization and debility. 
In some such instances a hypodermic of ] gr. of morphin will be 
required in order to soothe the patient's sufferings. In other 
cases a reliable hypnotic produces the desired results. Under 
such circumstances the choice of an hypnotic in the patient's de- 
bilitated condition is by no means a matter of indifference, as all 
hypnotics are to a greater or less degree depressants. Sodium 
bromid (10 gr.) combined with chloral (5 gr.), repeated every 
hour if necessary, yielded good results in the practise of the writer 
for several years. More recently, however, he has relied either 
on Formula %'^ or 84. It should be observed that in Formula Zt^ 
any possible depressant effect of chloral on the heart is guarded 



5l8 niSEASES OF THE NOSE, THROAT, AND EAR 

against by the addition of a small proportion of strychnin. Both 
Formula '^t^ and the succeeding Formula 84 usually produce sleep 
after one or two doses are taken, and are apparently free from 
any depressant after-effects. 

TONICS 

85. U Hydrarg. bichlor., gr. i ; ' * 

Acidi arseniosi, gr. \ ; 

Ferri pyrophos., gr. vj ; 

Quinise sulph., gr. xv. — M. 

Ft. pil. No. xxiv. 
Sig. I after meals. 

Useful as a tonic pill in catarrh of the nose and throat, with a 
debilitated condition of the system. 

86. R Tincturae gentianse comp., i%\} ; 

Elixir cinchonas, f5J ; 

Syrupi limonis, fo^s; 

Spiritis frumenti, q. s. ad. f^viij. — M. 

Sig. I or 2 tablespoonfuls in water before meals. 

A useful formula where it is desired to administer an alcoholic 
stimulant, but where it is undesirable from any cause to advise 
the use of whisky pure and simple. 

Z-]. H Ext. bellad. fol. ale, gr. iv ; 

Quin. sulph., gr. xxij ; 

Ferri sulph. exsic, gr. vij ; 

Strych. sulph., gr. i; 

Acidi arsenosi, gr. \ ; 

Oleoresince piperis, TTLviiss. — M. 
Ft. pil. No. XV. 
Sig. I pill three times a day. 

Jour, of the Avier. Med. Assoc. 

In the treatment of neuralgia of the ear, which is often a sign 
of defective nutrition and associated with anemia, the above 
combination is sometimes useful. 

MISCELLANEOUS 

88. R Contractile collodion. 

Contractile collodion is sometimes applied to a cicatrix or 
atrophic drum-head to hold it in a more favorable position for 
hearing. For this purpose, after inflation by Politzer's method, 
only a small amount of the collodion should Idc painted upon the 
drum-head at one time, as there is some danger of producing 
myringitis if too large an amount of the remedy is painted on 
the drum-head at one sitting. 



MISCELLANEOUS 519 

89. li Phospliotated oil. 

Forinerlv many ointments and solutions were a})plied to the 
membrana tymj)ani for the reliet" of tinnitus and deafness caused 
by catarrh of tlie middle ear. Although this form of medication 
has largely been abandoned, i)hosj)horus dissolved in olive oil, 
if applied to the drum-head, will sometimes bring about im- 
provement of the hearing in deafness due to senility. 

90. li Clilorofurnii. 

91. R lodini. 

92. U TincUinu iodini, f:^] ; 

.luher, f5J-— ^I- 

93. R Menthol. 

The vapor of these substances is sometimes used as an appli- 
cation to the mucous membrane of the middle ear. They should 
be preserved ready for use in wide-mouthed, glass-stoppered 
bottles, so that the Politzer air-bag can be filled with their vapor 
by placing the nozzle of the bag within the neck of the bottle 
while the bag is expanding. Ether and chloroform vapor will 
sometimes penetrate into the middle ear through the Eustachian 
tube when it is impossible to inflate the middle ear with simple 
air by Politzer' s method or the use of the catheter. 

94. R Tincture of gelsemium, 

Tincture of lobelin, da ^] ; 

Potassium bromid, ,'^ss. — M. 

Sig. 20 drops in water every three hours. 

pjurnett. 

The above is said to be almost a specific as regards relief in 
asthma. 

95. li Ac. carbol., gr. xxx ; 

Amnion, carb., ^] ; 

Pul. carbo. lig., ^j ; 

01. lavend., WLxx ; 

Tr. benzoin CO., ^^^'■< 

Gum camphor, ^V]. — M. 
Sig. — .Smelling salts for acute nasal catarrh. 

96. R Paraffin, ^iv ; 

Albolene, ^v. — M. 

Melt together in container surrounded by boiling water. 
Sig. For use as a subcutaneous injection for the correction of nasal 
deformities, etc. 



520 DISEASES OF THE NOSE, THROAT, AND EAR 

For subcutaneous injections sterile paraffin, with a melting- 
point of 112° F,, is usually employed. When the melting-point 
is much higher than this, it is not readily forced through a long 
needle and does not as readily penetrate the spaces of the cellular 
tissue. When the melting-point is much lower than 112° F., 
paraffin behaves more like ordinary oil, permeates the tissues 
more readily, and may enter a vessel and cause embolus. 

Ordinary commercial paraffin, whose melting-point is usually 
128° F., may be reduced to a melting-point of 112° F. by adding 
5 parts of albolene to 4 parts of paraffin, the mixture sterilized 
by boiling it and its container in water, and preserved for future 
use. 

Thus prepared the melted paraffin should be drawn into a suit- 
able syringe (Fig. 93), the nozzle of which is then closed with 
its screw cap. The syringe with the paraffin it contains and the 
necessary needle are then sterilized by boiling in water. The 
syringe and paraffin contained in it are then cooled in sterile 
water, the screw cap removed, the needle screwed in its place, and 
the instrument is then ready for use. 

97. R Acidi nitromuriatici 

(concentrated, freshly prepared), f^j, 

Sig. 5 to 10 drops in a tumbler of water after meals and at bedtime. 

In a large proportion of cases of hay-fever the above formula 
will eliminate all symptoms of the disease within forty-eight 
hours. If after two or three days' use of the remedy there is no 
improvement in the symptoms, it is probable that nitromuriatic 
acid will prove useless no matter how long continued. 

Mineral acids in the treatment of hay-fever are said to owe 
their efficiency to the fact that they diminish the alkalinity of the 
blood to an extent that it is no longer capable of holding in solu- 
tion uric acid, and hence the mucous membranes are no longer 
irritated by the secretion of this substance. However, in this 
connection it should be borne in mind that nitromuriatic acid has 
been employed for several generations as an alterative and tonic 
in gastro-intestinal diseases and in diseases of the liver, where it 
is said to increase the biliary secretions. It is probable, there- 
fore, that when exhibited in the treatment of hay-fever that it 
not only frees the blood from uric acid but also, by improving 
metabolism, limits the formation of uric acid and perhaps other 
products of defective metabolism. It should be borne in mind 
also in this connection that mineral acids were formerly used more 
frequently than at present in the treatment of diseases of the 
upper respiratory tract, 10 drops of dilute nitric acid every two 



M ISC EL LANEOUS 521 

hours in water being an old but usually effective remedy in the 
treatment of the aphonia of singers and orators. 

The use of nitromuriatic acid may be commenced at any time 
before or during the hay-fever season. It is important that the 
acid be freshly prepared. At first a colorless liquid, it becomes 
within a iQ.\\ days yellow. The yellow color deepens almost to 
brown, but finally again becomes lighter, until at length the 
mixture is colorless. During this period of change in color 
fumes are given off and the remedy is then thought to be most 
active in its effects upon the gastro-intestinal tract. When lo 
drops are diluted with a tumbler of water the water is only 
slightly sour to the taste, but it is well enough as a precaution 
against possible injury to the teeth to rinse out the mouth either 
with pure water or water to which a pinch or two of baking soda 
has been added. 

If the use of nitromuriatic acid is successful in eliminating the 
symptoms of hay-fever, it is probable that they will cease to recur 
as long as the patient continues to take the remedy regularly. 
However, should he neglect to take a single dose, more especially 
the evening dose, it is probable that some symptoms of the dis- 
ease will be quickly manifested. For example, if the evening dose 
be omitted, it is probable that the patient will wake up the next 
morning with his nose occluded and irritable and very likely 
will have several attacks of sneezing. 

Prolonged use of nitromuriatic acid is apparently harmless. 
Some of the writer's earlier cases have used the acid for months at 
a time year after year during the hay-fever season, and occasion- 
ally some of them during the winter season as well, without 
noticing any deleterious effects. In cases where the remedy is 
effective, it is curative to the extent that it almost completely con- 
trols the symptoms during the hay-fever season, and there seems 
a tendency for the attacks to become less and less severe from 
year to year. 

In neurotics suffering from hay-fever much benefit sometimes 
results from large doses (20 to 30 gr.) of bromid of sodium three 
times a day, which is ordinarily sufficient to control the violent 
attacks of sneezing. In such cases the following formula is often 
useful : 

98. R Acidi hydrobromici diluti, f^ij. 

Sig. 15 to 30 drops in a tumbler of water one hour after meals. 

Hydrobromic acid also yields in the majority of cases some- 
what better results in the treatment of tinnitus than bromid of 
sodium or the mixed bromids. 



522 DISEASES OF THE NOSE, THROAT, AND EAR 

99. K Ext. cimicifugae racemosse, fjij. 

Sig. 15 to 20 drops after meals and at bedtime. 

The above is sometimes useful in tinnitus. When effective its 
beneficial results are manifested within a few days. However, a 
rather large proportion of cases of tinnitus from chronic middle- 
ear catarrh are not benefited in the least by the use of cimicifuga. 

100. Ijt Atropinae sulphatis, g^"- 4 ; 

Acidi sulphurici aromatici, f^ij ; 

Aquae rosae, q. s. ad. f^j. — M. 

Sig. 20 to 30 drops at bedtime, repeated if necessary. Useful in the 
night-sweats of phthisis. 

101. li Acidi carbolici, gr. iij ; 

Pulveris camphorae, 

Resorcin, da gr. xx ; 

Acidi borici, gr. xxx ; 

Unguenti zinci oxidi, Jj. — M. 

Fiat unguentum. 
Sig. Use twice a day as an external application in acne rosacea of the 
nose. 

102. R Pilocarpinae hydrochloras, gr. -y-^-\- 

Pilocarpin may be given hypodermically once a day in con- 
junction with potassium iodid three times a day by the mouth in 
effusion or hemorrhage into the labyrinth, tertiary syphilis, and 
traumatism involving the internal ear. The average dose of 
pilocarpin is about yL gr. hypodermically, but much larger 
amounts have been used with impunity. When administered for 
its action on the internal ear a sufficient amount should be taken 
to produce profuse sweating or salivation. The remedy should 
be continued a sufficient number of days to produce the desired 
result, unless the patient becomes greatly prostrated by its con- 
tinued use or it is manifestly unavailing in the treatment of the 
internal ear disease. When no improvement is manifest after 
two weeks' use of the drug it should be abandoned. It rarely 
is of use except in acute cases. 

Pilocarpin is a drug whose action should be carefully watched, 
because serious and even fatal consequences have resulted from 
the injection of medicinal doses. Shoemaker cites a case where 
the patient suddenly expired after an injection of pilocarpin. In 
another case the same author states that the employment of \ gr. 
was followed by profuse diaphoresis, salivation^ lacrimation, a 
discharge from the nose, sickness of the stomach, difficulty in 
breathing, and a sense of cardiac oppression. Internal and external 
stimulation caused the symptoms to disappear. A tropin is a phys- 
iologic antidote to pilocarpin. 



FORMULAS FOR USE WITH NEBULIZERS 523 

Pilocarpi!"! may be given l)y the i!iouth instead of h)'])oder- 
mically, but its effects aie longer in !nanifesting themselves (fif- 
teen to twenty minutes) and moi^e uncertain. Politzer advises 
the injection of 6 to 8 drops of a warm 2 per cent, solution 
through the Eustachian catheter into the Eustachian tube in 
sclerosis of the !iiiddle ear. Mendosa, in 3 cases, relieved urgent 
dyspnea fro!n edema of the larynx by hypodermic injections of 
pilocarpin. 

FORMULAS FOR USE WITH NEBULIZERS 

In order to be successfully nebulized a fluid !nust have sufficient 
viscidity. Glycei-in nebulizes fairly well, but its nebulizing 
qualities are greatly improved by the addition of a s!nall propor- 
tion of tincture of benzoin. 1 he benzoin should be added drop 
by d!"op with constant stirring of the glycerin or shaking of the 
bottle which contains the glycerin in order to evenly diffuse the 
benzoin through the glycerin, which beco!nes white and opaque 
f!-0!n minute particles of benzoin suspended in the liquid. The 
!nixture is co!nparatively stable and the benzoin contained in 
about I dram of the tincture can thus be suspended in i ounce 
of glycerin. 

Ordinary bleached /^'/r^/^/^/w oil or albolene, with or without 
the proportion of benzoin it can be made to dissolve, nebulizes 
fairly well. 

Alcohol made viscid by the solution of one of the balsams, 
preferably benzoin, nebulizes fairly well. However, alcohol is 
somewhat irritating to the bronchial mucous me!nbranes, and in 
use the product of a nebulizer containing an alcoholic solution is 
best diluted by the product of one containing a bland oily solu- 
tion. 

The alcohol evaporates so!i-iewhat rapidly during the process 
of nebulization, so that the fluid in the nebulizer becomes more 
and more concentrated until, finally, the dissolved balsams are 
deposited within the nebulizer tubes and clog them up to an ex- 
tent to prevent the instrument working unless more alcohol is 
added from time to time to replenish that which has evaporated. 

Any substance can be nebulized successfully if reduced to a 
fluid state by solution in one of the above three liquids. Essen- 
tial oils and caiiiphors are best dissolved in albolene for nebuliza- 
tion ; substances insoluble in oil, either in the glycerin mixture 
or in alcohol. 

11ie following fomiulas may pi'ove useful when used with a 
nebulizer. They should not be used with an atomizer, because 



524 DISEASES OE THE NOSE, THROAT, AND EAR 

the amount of fluid deposited on mucous membranes by an 
atomizer is many times greater than that derived from a nebulizer, 
and some of the following solutions are sufficiently concentrated 
to produce deleterious results if applied to the nose or pharynx 
by means of an atomizer. The fact that only a minute amount 
of nebulized fluid is deposited on the mucous membrane of the 
upper respiratory tract during the short time available for the 
treatment of a patient during an ordinary office visit, probably 
accounts for the lack of enthusiasm manifested by many special- 
ists for this method of treatment. The atomizer will probably 
always be the favorite instrument for applying remedies to the 
nose, pharynx, and larynx of office patients. 

However, for the patient's use at home, especially when the 
circumstances are such as to allow the patient to devote con- 
siderable time to the treatment of his condition, the nebulizer 
possesses advantages that should not be overlooked. Also in 
children sufficiently nervous to be terrified by an atomizer spray, 
the nebulizer can be used to advantage. If necessary the nebulized 
fluid can be conveyed by a long rubber tube underneath a tent 
improvised by throwing a sheet over the shoulders of a nurse 
while the child is seated in her lap. By this method the air sur- 
rounding the little patient can be saturated with the nebulized 
vapor, thus securing a prolonged and thorough application of the 
remedies without producing the struggle and fright so frequent 
when an atomizer is employed in young children. 

103. Ijt Ex. ipecacuanha, f^j ; 

Glycerini, f^ij ; 

Tr. benzoin comp., f^j. — M. 

For use in nebulizer to relieve dryness in throat. Increases 
fluidity of secretions. 

104. R Olei cinnamomi, TTtxx ; 

Olei eucalypti, 'nix>; ; 

Menthol, gr. xl ; 

Camphor, " gr. Ixxx ; 

Albolene, fjviij. — M. 



Porch. 



Antiseptic, emollient. 

105. R lodin, gr. xvj ; 

Camphor, ^^j ; 

Menthol, ,^j ; 

Oil pine-needles, ,^ij ; 

Albolene, fjviij. — M. 



FORMULAS FOR USE WITH NEBULIZERS 525 

For acute and subacute coryza, catarrh in the head passages, 
dry catarrh, ozena, and rhinitis. May be used regularly by pub- 
lic speakers, singers, actors, etc. A pleasant stimulant and pro- 
tective. 



106. 


li Liq. adrenalin chlorid (l : 5000), 


f3J; 




Menthol, 


gr. xl ; 




Oiei gaultheriae, 


TTlxx; 




Cilyceriiii, 






Aqiuie dcstil., 


f^viij. — M. 



fjiv 


.— M. 




gm. 


I ; 




gm. 


2.5; 




gm. 


2-5; 




gm. 
gm. 


■5; 

93-5.- 
McCli 


-M. 

intock. 



For severe or chronic cases of hay-fever. Constringent, hemo- 
static, local anesthetic, antiseptic. 

107. li Terebeni, 

Oiei eucalypti, 
Glycerini, 

For catarrhal conditions and as an antisepti 

108. K Chloietone, 

Camj^hor, 
Menthol, 
Oil cinnamon, 
Albolene, 

Anodyne, antiseptic, emollient. Useful in acute and subacute 
catarrh and bronchitis. 

According to the manufacturers balsamol is a combination of 
balsam of Tolu, benzoin, balm of Gilead, and myrrh, with oil of 
Scotch pine dissolved in alcohol. Respiral is a combination of 
albolene and cocoanut oil. NabuUn is a glycerin compound. 
These compounds are used to dissolve the other ingredients in 
the following ''Globe" formulas and render them capable of 
nebulization : 

109. R Oil eucalyptus, '7^]\ 

Oil cassia, Tllxxx ; 

Menthol, gr. xx ; 

Balsamol,! q. s. ^iv.— M. 

Use with nebulizer for simple catarrh of the nose, throat, and 
bronchial tubes, and after the first stage in all acute affections ; 

^ If the vapor from balsamol and other alcoholic solutions should seem 
uncomfortably pungent when applied directly to the nasal mucous membrane, 
it should at first be diffused or diluted either by using a mask or by holding 
the nasal tip near, instead of placing it in, the nostril, gradually increasing to 
full strength. Where a multinebulizer is used, the vapor may be diluted with 
that from a mild oil solution like Formula 114. 



526 DISEASES OF THE NOSE, THROAT, AND EAR 

also as a preventive during epidemics of the contagious diseases, 
and in any case where an antiseptic and healing action is desired. 
Alcohol should be added occasionally as the fluid becomes too 
thick from evaporation. 

no. B Menthol, gr. XXX ; 

Camphor, gr. xxx ; 

Cocain muriate, gr. xv ; 

Balsamol,^ q. s. ^iv. — M. 

Use with nebulizer for acute bronchitis, pneumonia, and all 
acute inflammatory affections of the air-passages. Alcohol should 
be added occasionally as the fluid becomes too thick from evapo- 
ration. 

III. K Oil cloves, Tllxxx; 

Creosote (beechwood), 3J ; 

Oil tar, 5J ; 

lodin, gr. xxx ; 

Balsamol,^ q. s. 5iv. — M. 

Use with nebulizer for pulmonary and laryngeal tuberculosis, 
and in any condition requiring an active antiseptic. Alcohol 
should be added occasionally as the fluid becomes too thick from 
evaporation. 



;. K Chloretone, 


3iv; 


Resorcin, 


gr. XX ; 


Quinin hydrobromate, 


•^^j' .. 


Balsamol,^ 


q. s. ,^iv. — M, 



Use in nebulizer for hay-fever, asthma, whooping-cough, etc. 
Alcohol should be added occasionally as the fluid becomes too 
thick from evaporation. 

113. R Chloretone, ^ij ; 

Todin, gi-;. xl ; 

Creosote, .^ij ; 

Balsamol,! q. s. ,^iv. — M. 

Use in nebulizer for tuberculosis with irritable cough, and in 
any condition requiring an alterative, antiseptic, and sedative 
action. Alcohol should be added occasionally as the fluid becomes 
too thick from evaporation. 

114. H Oil cassia, TnL>^xx ; 

Camphor-menthol, ^ij ; 

Cocain alkaloid, gr. viij ; 

Respirol, q- s. ^iv.— M. 

1 See note under Formula 109. 



FORMULAS FOR USF WITH NEBULIZERS 527 

Use with nebulizer for acute colds, sore throat, and in all cases 
of acute inflammation or congestion of the upper air-passages and 
middle ear. 

115. H Oil cloves, TTlxl ; 

Oil gaultheria, 3J ; 

Cocain alkaloid, gr. xv ; 

Menthol, gr. xl ; 

Respirol, q. s. ^^iv. — M. 

Use with nebulizer for acute bronchial and pulmonary con- 
gestion and inflammation, also in irritable cough of tuberculosis. 
It is both sedative and antiseptic. 

116. H 



Chloretone, 


gr. xl 


Camphor monobromate. 


3J; 


Camphor-menthol,' 


3J; 


Oil sassafras, 


HJ; 


Respirol, 


q. s. |iv.- 



-M. 

Use with nebulizer for irritable and ulcerated conditions of 
throat. 

117. 



Chloretone, 


gr. 3 


Camphor-menthol, 


3J; 


Oil pinus pumilionis, 


5J' 
q. s. 51V 


Respirol, 



gr. XXX 



M. 

Use in nebulizer for nasopharyngeal and bronchial catarrh with 
a tendency to hay-fever or asthma. 

118. li Chloretone, gr. xl ; 

Camphor monobromate, "7^} ; 

Camphor-menthol, ^j ; 

Cocain alkaloid, 

Oil anise, ^^^j ; 

Oil bitter almonds, _:^j ; 

Respirol, q. s. ^iv. — M. 

Use in nebulizer for relief of acute paroxysms of asthma, croup, 
hay-fever, whooping-cough, etc. 

119. H Oil terebinth, (rectified), !^iv ; 

Cocain alkaloid, gr. xv ; 

Respirol, q. s. ^iv. — M. 

Use with nebulizer for pulmonary hemorrhage. 

120. R Formaldehyd (40 per cent. ), :^iss ; 

Ext. sarsaparilla cap. fl., ^^iv ; 

Nebulin, *^j ; 

Water, q. s. 5iv.— M. 



528 DISEASES OF THE NOSE, THROAT, AND EAR 

Use in nebulizer for diphtheria, tonsillitis, hay-fever, and all 
diseases of a zymotic origin, and in all conditions requiring an 
active germ destroyer. 

121. Ijt Tannic acid, ^j ; 

Nebulin, ^j ; 

Cinnamon -water, q. s. ^iv. — M. 

Use with nebulizer in relaxed conditions of mucous membrane 
and in passive congestion. It is a simple astringent. 

FORMULA FOR THE BOTTLE INHALER, CROUP 
KETTLE, ETC, 

The steam from a kettle containing unslaked lime has been used 
for many years in the treatment of croup and diphtheria. 

A croup kettle consists usually of a vessel with a long spout, 
to which a rubber hose is attached, by means of which steam 
is conveyed to the vicinity of a patient or under a croup tent 
erected over a bed. As the quantity of unslaked lime that will 
dissolve in water is not great, a piece of lime the size of a 
walnut is more than sufficient for several quarts of boiling 
water. 

The following formula may be used with the bottle inhaler or 
added to the water in a teapot containing boiling water. 

122. R Tr. benzoin comp. 

Sig. Add \ teaspoonful to a bottle inhaler half-full of hot water. Use 
the inhaler four or five times a day. 

Useful in most forms of laryngeal inflammation. To the 
above formula, when requisite, an expectorant — ammonia 
muriat., fluid extract of senega, or ipecac — may be added. 
When it is desired to diminish expectoration and at the same 
time produce a sedative effect upon the laryngeal mucous mem- 
brane, fluidextract of belladonna or hyoscyamus in combination 
with the compound tincture of benzoin will yield satisfactory 
results. 

COUGH MIXTURES 

Although remedies designed to affect the respiratory tract are 
best administered by means of an atomizer or nebulizer, and 
when that is impossible or inconvenient in the form of a lozenge, 
yet the cough mixture still retains at least a measure of its 
former popularity. The following formulas are effective and 
sometimes convenient to prescribe : 



COUGH MIXTURES 529 

123. IJ Syrup ipecac, (5ss; 

Syrup scilhv, f^vj ; 

Liq. potass, citrat., f?j ; 

Mucil, acacia;, q. s. ad. f^iij. — M. 

Sig. I tcaspoonful in water every three liours. 

Ilaehnlen. 

Useful for controlling the coughs of children. 

124. H Potassii bromidi, ^ss ; 

Potassii cyanidi, gr. iss ; 

Ext. prunus virginiani, f^^ss ; 

Ext. grindelia robustce, fjiij ; 

Muc. acaciac, 

Aquae dest., dd q. s. ad. fjiv. — M. 

Sig. 1 teaspoonful in water four times a day. 

Useful in the so-called " useless or dry cough " of nervous 
individuals due to pharyngeal irritation. 

125. U Morph. sulph., gr- j 5 

Syr. limonis, • ^ij ; 

Syr. scillce, 

Syr. pruni virg., dd ^]. — M. 

Sig. I teaspoonful every four hours. 

126. ifc Morphin?e sulphatis, gr. ss-ij ; 

Potassii cyanidi, gr. iij ; 

Acidi sulphurici aromatici, %'-iJ 5 

Syrupi pruni virginianre, q. s. ad. f^iij- — M. 

Sig. I teaspoonful every two or three hours if required to prevent 
coughing. 

Useful as an anodyne, but somewhat stimulating cough mixture. 

127. U Amnion, carb., ^ij ; 

Syr. seneg?e, ^] ; 

Aq. fontan., ^iij. — M. 

Sig. I teaspoonful every two or four hours. 

Useful as an expectorant. 

12S. R Codeinje sulph., gr. iv; 

Syr. glycyrrhizae, 

Syr. tolutani, dd 3J.— M. 
Sig. I teaspoonful every two or four hours. 

129. R Codeinae, gr. iv ; 

Acidi hydrocyanic! diluti, tttxxxij ; 

Syrupi tolutani, q. s. ad. f^^ij. — M. 

Sig I teaspoonful three or four times a day. 

Da Costa. 

Both the above are most useful as sedative cough mixtures. 
34 



530 DISEASES OF THE NOSE, THROAT, AND EAR 



130. 


K: Heroin, 




g'- J ; 




Creosoti, 




m^vj ; 




Eucalyptoli, 




gr. viij ; 




Strycbnioe sulphatis, 




gr. i; 




Terpin hydratis, 




3ss; 




Syrupi aurant. cort., 








Mucilag. acacice, 




aa 5J. — M. 


Sig. 


I teaspoonful every three or 


four hours. 




131- 


li Terpin hydratis, 




gr. xxxvj 




Heroin hydroch., 




g»"- J ; 




, Ext. sumbiil, 




gr. xij ; 




Ytxxx valerianaiis, 




gr. xij.— 




Fiat capsul. No. xii. 






Sg- 


I every four hours. 







M. 



GARGLES 

Gargles are of little value unless employed with more than 
the usual care. Pope, by means of experiments with methylene- 
blue and other substances, demonstrated that as ordinarily per- 
formed gargling does not bring a medicament in contact with 
the fauces further back than the anterior pillars. When neces- 
sary to prescribe a gargle the patient should be instructed to close 
the nose tightly, throw the head far back, and gargle. By this 
method the probability of the fluid reaching the posterior wall of 
the pharynx is increased. Children cannot use a gargle, and 
rarely is it practical to teach a patient to gargle properly during 
an ordinary ofhce visit. Gargles as ordinarily employed rarely 
reach the posterior wall of the pharynx and never the larynx. 
However, the following are cheap astringent gargles, and they 
may at some time be convenient to prescribe. The small amount 
of the gargle swallowed is, of course, effective. 

132. R Glycerol tannici, ^j. 

Sig. I teaspoonful in a half-tumbler of vv'ater. Use as a gargle. 

Astringent gargle. 

133. R Alcoholis, 95 percent. 
Sig. Use as a gargle. 

Antiseptic and astringent. 

134. R Listerin. 
Sig. Use as a gargle. 

Sedative and antiseptic. 

135. R Acidi tannici, 

Acidi gallici, aa gr. xx. — M. 

Sig. Add to a tumblerful of water. Gargle and swallow a portion. 

As a styptic after tonsillotomy to control oozing of blood. 



LOZENGES 53 

136. li Hydrogen (lioxid, 15 voIuiiil'S (3 per cenl. ). 

Sig. Use as a gargle lo control oo/.iiig ol' blood after loiisilloloiny. 

U7- li Tincturx ferri chloridi, £31]; 

Potassii bromidi, 3U » 

Potassii chloratis, ^iij ; 

Ext. glycyrrhiza, 3J ; 

AqiKV, q. s. ad. I'^vj.— M. 

vSig. I teaspoonful in water every two hours, gargle and swallow. 

Useful in acute pharyngitis and tonsillitis. 



LOZENGES 

Lozenges, when well made, are superior to cough syrups or 
gargles for the treatment of throat affections. The excipient for 
each formula should be selected for its harmony with the active 
drug and its solubility. They should be so made as to dissolve 
sknoly and evenly in the mouth, thereby giving a more prolonged 
local effect than is possible with gargles or a spray, and a c|uicker 
and more pronounced result than can be obtained by a greater 
quantity of the medicant introduced into the stomach. 

The favorite excipients seem to be black-currant paste and gel- 
atin. Because of the length of time required for the drying of 
lozenges, druggists cannot quickly make them from the prescrip- 
tion of a physician, and it is therefore better in most instances to 
rely on the manufactured product of lozenge-makers, some of 
whom have national or international reputations. 

A business man can carry a bottle of lozenges in his vest 
pocket and take one as required from time to time, when he 
would be embarrassed by the use of an atomizer. 

However, it should be remembered that lozenges produce both 
a local and a coiistitutional effect and are only especially useful 
Avhen this effect is desired. Where the constitutional effects of a 
drug is not desired its use in the form of a lozenge is less desir- 
able than that of a spray, although the spray may be much more 
inconvenient for the patient. 

Lozenges have in common with cough mixtures a notorious 
reputation for disordering the stomach. This is largely due to 
the character of the excipient and the method of manufacture. 
Most of the following formulas have been selected from the 
stock lozenges of manufacturers. Among those the writer has 
found most useful are — 



532 DISEASES OF THE NOSE, THROAT, AND EAR 

GUAIACUM AND ITS COMBINATIONS 

"In cases of deep tonsillitis there is, fortunately, a remedy 
which, if administered at the outset of the attack, will almost 
always cut short the crescent inflammation. This is guaiacum. I 
prescribe it as a lozenge. Taken in this way it seems to have a 
local as well as a constitutional effect." — Morell Mackenzie. 

138. IJ Troch. guaiac,. gr. ij. 

The lozenges are stimulant and alterative, and are capable of 
arresting recent inflammation of the tonsils. 

These lozenges should contain 2 gr. of the resin of guaiacum 
and made in accordance with Mackenzie's formula, so as to be 
efitirely soluble in the mouth. They are useful in the treatment 
of acute and subacute inflammation of the pharynx and acute 
follicular disease of the tonsils. 

Mackenzie claims that guaiacum is a specific in acute tonsillitis, 
and Sajous is equally emphatic in praise of the remedy. 

139. Troch. guaiac. comp. 

R Resin guaiac, gr. ij ; 

Potassii iodid, gr. j. — M. 

Wm. Pepper. 

Stimulant and alterative. Efficient in throat disorders with 
syphilitic taint. Is especially useful when in acute inflammations 
of the tonsils there is a sensation of dryness, as the iodid increases 
secretion. 

140. Troch. guaiac. et acidi tannici. 

H Resin guaiac, gr. iss ; 

Acidi tannici, gi". \. — M. 

Sig. I lozenge to be dissolved slowly on the tongue every one or two 
hours. 

Stimulant and astringent, probably the most useful of the 
guaiacum lozenges in acute and subacute inflammation of the 
tonsils, pharynx, and larynx. Useful in the so-called "relaxed 
throats " of public speakers. They are especially useful inhyper- 
emic throat disorders caused by cold and damp atmospheric con- 
ditions. The astringent action of the tannic acid is greatly 
assisted by the alterative effect of the guaiacum upon the con- 
gested mucosa, and they effectively reduce the capillary tension 
and quickly relieve the inflammation. They are pleasant to ad- 
minister and do not constipate. 

141. Troch. guaiac. and benzoic acid. 

R Resin guaiac, gr. ij ; 

Acidi benzoici, gr. j. — M. 

J. F. Martenet. 



LOZENGES 533 

Stimulant in nervomuscular weakness of the throat. It is 
somewhat useful in tlie treatment and the loss of control of the 
laryngeal muscles experienced by nervous actors, singers, and 
orators, and those of these professsons who have lost confidence 
in their ])owers as the result of subacute inflammation of the 
pharynx and larynx. In addition to the lozenge, J„ gr. of 
strychnin or i dram of fluidextract of cocoa in i ounce of sherry 
wine may be prescribed, to be taken a few moments before going 
upon the stage or platform. 

Any one of the above guaiacum lozenges may be used every 
one, two, or three houns, according to the acuteness of the 
inflammation. 

CAMPHOMENTHOL AND ITS COMBINATIONS 

142. R Troch, camphomenthol, gr. J^. 

Sig. I lozenge dissolved on the tongue every hour or two, as required. 

These lozenges exert a more soothing and corrective effect upon 
the nerves and blood-vessels of the mucosa than do the usual 
preparations of menthol. They check excessive discharges, liquefy 
tenacious mucus, correct perverted secretions, and are an excel- 
lent voice stimulant. 

143, Troch. camphomenthol et eucalypti. 

R Eucalyptus rostratce (red gum), gr. j ; 

Camphomenthol, gr. yL. — M. 

Sig. I lozenge dissolved on the tongue every hour or two, as required. 

A pleasant antiseptic astringent, with sedative effect upon irri- 
tations of the mucosa. 

When greater anodyne effect is desired, in acute or chronic 
bronchitis, the following is an efficient and reliable sedative : 



144. Troch. codein comp, 

R Codeinae, gr. 



JL . 
10 ' 



Camphomenthol, gr. J^. — M. 

Sig. I lozenge to be dissolved slowly on the tongue every one or two 
hours if required to prevent coughing. 

145. Troch. heroin. 

K Heroin, gr. J^ ; 

Camphomenthol, gr. J^. — M. 

Sig. I lozenge every two hours if required to relieve cough. 

146. Troch. orthoform comp. 

R Orthoform, gr. j ; 

Camphomenthol, gr. -^-^. — M. 

Fiat troch. No. i. 
Sig. I ten minutes before meals or as required, as a safe analgesic after 
throat operations and other pamful conditions of the pharynx and larynx. 

McConachie. 



534 DISEASES OF THE NOSE, THROAT, AND EAR 



COCAIN AND ITS COMBINATIONS 

Instead of the above orthoform lozenge, either of the two fol- 
lowing may be employed in the dysphagia of tuberculous laryn- 
gitis, where greater analgesia is required : 

147. Troch. cocain comp. 

R Cocain hydroch., g^'- To 5 

Extract, hyoscyami, gr. J^ ; 

Extract, opii, gr. J^ ; 

Tincturae aconiti, TTLt- — ^I- 

Sig. I lozenge a few muments before eating and every two or three 



hours 



J. J. Chisholm. 



This combination is of considerable value as an anesthetic and 
anodyne in the laryngeal lesions of phthisis and to control the 
paroxysms of asthma. 

148. H; Cocain hydrochloridi, gm. 0.002 ; 

Acetanilid, gm. 0.02. — M. 

Fiat troch. No. i. 
Sig. I four to six times a day. 

Winslow. 

These lozenges have a pungent taste and leave an agreeable 
tingling sensation in the throat. They are useful in chronic 
pharyngitis associated with painful deglutition, paresthesia, and 
various neurotic sensations. 

149. H Cocain hydrochloridi, gr. i-1. 
Fiat troch. No. i. 

Sig. I before meals to relieve painful deglutition in tuberculosis, cancer, 
etc., of the larynx. 

AMMONIUM SALTS AND THEIR COMBINATIONS 

Am.monium salts have long been used in the treatment of 
pharyngitis and bronchitis. They may be given in the form of 
a lozenge for the local effect on the pharynx, but the lozenge 
should be so made that the ammonium salts do not dissolve more 
rapidly than the other ingredients of the lozenge. 

150. R Troch. glycyrrhiza comp. 
Sig. I lozenge every two or three hours. 

Brown mixture lozenges should be so made that each lozenge 
corresponds to a teaspoonful of the well-known *' brown mixture. ' ' 



LOZENGES 535 



151. B Trocli. ammonia.' comp 
Sig. I every two or three hours. 



Pennsylvania Hospital formula. 



152. li Ammoniix: chloridi, gr. ij. 

Fiat troch. No. i. 
Sig. I every two or three hours as a stimulating expectorant. 

Morell Mackenzie, 



153- 


Troch. amnionirc iodidi comp. 








li Amnionire iodidi, 




gr. j; 




Ammoni.x chloridi, 




i;r. ij ; 




Codeincc, 




gr- i ; 




Morphince acetatis, 




^"^i. 




Ext. prunis virginiance, 




q. s.— M. 




Fiat troch. No. i. 






Sig. 


I every three hours as an alterative, 


sedative. 


ex|)ectc)rant. 



MISCELLANEOUS 

Some of the prescriptions under this heading are old favorites 
and have been popular with many physicians for years. 

The three next lozenges may be given to children and adults 
who strenuously refuse any remedy having an unpleasant taste, as 
they are as pleasant as a confection. 

154. Troch. mucilag. ulmi (mucilage of slippery elm). 

B Mucilag. ulmi, q. s. 

Facio troch. No. i. 

These lozenges are probably the best demulcent in painful con- 
ditions of the pharynx. They are vastly different from the 
ordinary ''slippery elm lozenges," made by grinding up the 
bark of the elm tree and mixing it with gum and sugar. 

1 55- R Ipt-'cacuanhce. 

(Allen & Hanbury's, Ltd., London.) 

These are large gum arable pastils of the same strength as 
the lozenges of the British Pharmacopoeia. They are readily 
taken by children and exert the expectorant effects of ipecacuanha 
with the demulcent characteristics of the lozenge. 

156. 



Troch. acidi borici compositas, 






R Acidi benzoici. 


gr. ss ; 




Acidi borici. 


gr- j ; 




Ext. erythrox. cocce. 


gr. iss. 


— M. 

Faulkner 



536 DISEASES OF THE NOSE, THROAT, AND EAR 

This lozenge is sedative, demulcent, and of a pleasant taste. 
It is a valuable voice lozenge in cases of orators and singers of the 
neurotic temperament, who dread that their voice will fail them 
in the presence of an audience because of nervous muscular 
weakness. One should be slowly dissolved in the mouth every 
four hours. When used as a ''voice lozenge " one should be 
taken one-quarter of an hour before using the voice and fluids 
should be avoided. 

157. Troch. acidi cavbolici. 

R Acidi carbolici, gi"- j- 

Fiat troch. No. i. 

Morell Mackenzie. 

This formula has long been a favorite as an analgesic, anti- 
septic lozenge. 

158. Troch. potassse chloratis et acidi tannici. 

R Potassae chloratis, gr. iij ; 

Acidi tannici, gr. ss. — M. 

Antiseptic and astringent. Is especially valuable in severe 
acute pharyngitis, where the mucous membrane is dusky red, 
much swollen, and ''glazed " from scanty secretions. 

159. Trochisci kramerise (rhalany). 

R Ext. kramerise, gr- j. 

Sig. 1 every hour. 

Astringent. 

160. R Potassii chloratis, 

Potassii bromidi, 

Ext. glycyrrhizae, aa gr. iij ; 

Tr. ferri chloridi, TTLiss.— M. 

Sig. I every two or three hours. 

Seiler. 

Useful in acute pharyngitis, tonsillitis, and laryngitis. 



INDEX 



AiJDUCTOR paralysis of larynx, 270 
Abraham's tonsil knives, 220 
Abscess, extradural, from otic disease, 

475 
in mastoid, perforation of, 468 
of cerebellmn from otic disease, 

478 
of cerebrum from otic disease, 

478 
of membrana tympani, 366 
of nasal septum, 152 
retropharyngeal, 208 
subdural, in otic disease, 475 
Accessory sinuses of nose, diseases of, 

differentiation, 159 
inflation of, by Politzer's air- 
bag, 165 
by Valsalva's method, 166 
Acetanilid, 514 
Acoustics, 308 

Actinomycosis of pharynx, 207 
Adam's apple, 229 
Adams' septum forceps, 154 
Adductor muscle, spasm of, 266 

paralysis of larynx, 269 
Adenoids of middle ear, 380 

of pharyngeal tonsil, 189 
Aditus ad antrum, 298 
Adnephrin, 502 
Adrenalin, 497, 502 

effects of, on heart, 503 

for epistaxis, 503, 504 

in hay-fever, 503 

internally, 503 

secondary hemorrhage after, 502 
Air-bag, Politzer's, 321 
Air-compressors, cut-off for, 52, 53 

for atomizers, 50 
Aire of nose, 65 
Albolene as nebulizer, 523 

fluid, 498 



Albuminuria in croupous tonsilliiis, 

216 
Alcohol, 509 

as nebulizer, 523 

flaming, for sterilization, 59 
Alkalol, 496 
Allen's nasal applicator, 46 

with Gottstein's cotton plug, 
102 
speculum, 35, 36 

probe, 46, 85, 86 

as applicator in Eustachian tube, 

328 
for removing cerumen, 353 
Alligator nasal cutting forceps, Myles', 

182 
AUport's dilator, 466 

middle-ear forceps, 437 
Alpha-eucain, 502 
Alphasol, 495 
Alteratives, 515 
Alypin, 501 

Ammonium salts lozenges, 534 
Amygdalitis, 214 
Analgesics, 499 
Anemia of labyrinth, 490 

of larynx, 239 
Anesthesia of larynx, 264, 500 

of nasal mucous membrane, 1 1 1 

of nose, 499, 500 

of i^harynx, 210 
Anesthetics in hypertrophy f)f tonsil, 
192 

local, 499 
Aneurism of aorta, laryngeal paral- 
ysis of, 236 
Angina catarrhalis, 194 

chronic, 195 

faucium, 214 

tonsillaris, 214 
Angioma of nose, 124 
Ankylosis of stapes, 426 

537 



53B 



INDEX 



Annulus tympanicus, 297, 448 
Anosmia, no 
Antipyrin, 505 
Antitoxin, diphtheria, 2S0 

hay-fever, 115 
Antrum of Highmore, illumination of, 
163, 164 
inflammation of, 161 

Caldwell -Luc operation for, 

169 
cleansing opening, 168 
diagnosis, 161 
drainage in, 166 
Jansen's operation for, 169 
Kuster's operation for, 169 
symptoms, 163 
treatment, 1 64-1 71 
size of, 168 
Anvil bone of ear, 299 
Applicator, Allen's, with Gottstein's 
cotton plug, 102 
cotton, 45 
nasal, Allen's, 46 
Argyrol, 510 
Aristol, 514 
Aryepiglottic fold, 29 
Arytenoid cartilages, 29, 231 

pyriform, 253 
Arytenoideus muscle, 233 
Asch's compressing forceps, 141 
operation for deviated septum, 141 
scissors, 141, 142 
separators, 142 
Asthma, in 

miller's, in 
Astringents, 508 
Atomizer, 46 

air-compressors for, 50 
at home, 46, 50 
DeVilbiss, 48, 51 
Atrium of tympanum, 296 
Atrophic catarrh, 70 
Attic of tympanum, 296 
wall, removal of, 437 
Auditory canal, external, 293. See 
also External auditory canal. 
nerve, 306 
Aural auscultation-tube, 319 
cholesteatoma, 358 
masseur, 44, 45 
polypi, 405 

removal of, anesthesia for, 501 
stethoscope, 319 



Auricle of ear, 292 

absence of, 329 

arteries of, 293 

burns of, 335 

chancre of, 337 

congenital defects of, 329 

cutaneous diseases of, 333 

dermatitis of, 334 

eczema of, 339 

erysipelas of, 337 
phlegmonous, 338 

frost-bite of, 334 

gangrene of, 339 

gumma of, 337 

herpes of, 335 

hyperemia of, m 

impetigo contagiosa of, 336 

keloid of, zy^ 

lobule of, cleft, 333 

lupus vulgaris of, 336 

multiple, 329 

muscles of, 293 

nerves of, 293 

new growths on, 341 

othematoma of, 330 

perichondritis of, 330 
chronic, 332 

syphilis of, 337 

veins of, 293 

wounds of, 332 
Auscultation of ear, 325 
Auscultation- tube, aural, 319 

Toynbee's, 320 
Autolaryngoscopy, 27 
Autophony, 385 
Autoscope, 30 

Autoscopy, advantages of, 33 
instruments for, 32 
of larynx, 30 
of trachea, 30 
Autumnal catarrh. III 
Axial ligament of malleus, 299 

Bali^knger's operation for deviated 
septum, 145 
septum knife, 146 
swivel knife, 147 
Balsamol, 525 

Bell's palsy from otic disease, 483 
diagnosis, 486 
prognosis, 487 
symptoms, 485 
treatment, 488 



INDEX 



539 



iJenzoinol, 499 
lieta-cocain, 502 
IJing'.s test for liearin<r, 316 
niakc's poly[)us snare, 399 
Ijoekel's automatic cut-otf, 53 
IJone drills, 94 

electric motor, 95 
for exostosis of septum, 95 
Hone-curet, double-end, Gleason's, 464 
lione-cutting forceps, Gleason's, 155 
Ijoric acid powder, 512 
l>orolyptol, 496 
IJosworth's nasal saw, 93 

operation for deviatctl septum, 133 

tongue-depressor, 28 
Boucheron's specula, 41 
Bougies, Eustachian, 328 

in exploring Eustachian tubes, 323 
Brain complications of mastoiditis, 456 

of otic disease, 475 
Bii<lge of nose, 64 

flattening of, 154 
Bright's disease, otitis media from, 415 
Browne's hollow laryngeal dilator, 251 
Brunton's otoscope, 40 
Buckhn's nasal reversil)le saw, 93 
Burns of auricle, 335 
Bursitis, chronic, 193 

Cadaveric position of vocal cords, 

271 
Calcium chlorid, 504 
Caldwell-Luc operation for disease of 

antrum of Ilighmore, 169 
Camphomenthol lozenges, 533 
Camphor, 498 
Canalis reuniens, 303 
Cancer. See Carcincwia. 
Cannula, frontal sinus, Hartmann's, 
176 

Halle's, 167 
Carbolic acid, 500 
Carcinoma of larynx, 260 
treatment, 260 

of nose, 124, 127 
Caries in mastoiditis, 454 

of temporal bone, 408 
Caroid, 497 

Carotid artery, position of. 437 
Cartilages of Santorini, 30, 232 

of Wrisberg, 30, 232 
Catarrh, acute, 70 

atrophic, 70 



I Catarrh, autumnal, ill 
chronic, 70, 75 
dry, 70, 98 
nasal, acute, 74 

atrophic, 98 

hypertrophic, 80 
nasopharyngeal, ear disease from, 

of antrum of Ilighmore, acute, 161 

chronic, 166 
of ethmoid cells, 179 
of frontal sinus, acute, 171 

chronic, 175 
of middle ear. See Otitis media. 
of throat, chronic, 195 
pharyngeal, acute, 194 
postnasal, 188 

ear disease from, 318 
syphilitic, 104 
Catching cold, 69, 72 
Catheter, Eustachian, 322 
Hartmann's, 322 
inflation of middle ear through, 

326 
introduction of, into Eustachian 

tubes, 323 
medication through, 326 
spraying through, 326 
test of patency of Eustachian tubes, 
321 
Catheterization of Eustachian tubes, 
321 
introduction of catheter, 323 
obstacles, 324 
Caustics, 83, 508 
Cautery batteries, 86 

knives, 87 
Cerebellum, abscess of, from otic dis- 
ease, 478 
Cerebrum, abscess of, from otic dis- 
ease, 478 
Cerumen, impacted, 354 

removal of, 353 
Cerumenosis obturans, 354 
Chalk deposits on membrana tympani, 

367 
Chancre, nasal, 104 

of auricle, 337 
Chink of glottis, 235 
Chisels, mastoid. Whiting's, 465 
Chloral, 500 
Chlorid of calcium, 504 
Chloroform, 519 



540 



INDEX 



Choanae, t^}^ 

Cholesteatoma, aural, 358 

Chorea, laryngeal, 265 

Chromic acid for removing hyper- 
trophies, 86 

Circumscribed inflammation, acute, 
of external auditory canal, 341 

Cleft lobule of auricle, -^it^ 

Clergyman's sore throat, 196 

Clevenger's medication instrument, 

3-7 
Cocain hydrochlorate, 499 

in lanolin, 501 

lozenges, 534 
Cochlea, 303 

functions of, 307 
Cold, chronic, 75 

in the head, 72, 74 
Ct)llodion, contractile, 518 
Columnar cartilage, dislocation of. 

Concussion of labyrinth, 491 
Cone of light, 362 
Contractile collodion, 518 
Corti's organ, 304 
Coryza, 74 

chronic, 75 

syphilitic, 104 

vasomotoria periodica, in 
Cosmolin, 498 
Cotton applicator in otoscopy, 45 

cones, 342, 343 

cylinders for treating atrophic rhi- 
nitis, 102 
Cough, III 

laryngeal, spasmodic, 265 

mixtures, 528 

useless, 197 
Cow cold. III 

Crico-arytenoideus lateralis muscle, 
234 

posticus muscle, 234 
Cricoid cartilage, 230 
Cricothyroid muscle, 234 
Croup, false, 266 

kettle, 528 

formula for use with, 528 
Croupous inflammation of the Schnei- 

derian membrane, 71 
Curet, bone, Gleason's, 464 

laryngeal, Harland's, 256 

mastoid, McKernon's, 462 
Cusco's laryngeal forceps, 262 



Cutaneous diseases of auricle, y^2> 
Cynanche tonsillaris, 214 
Cyst of auricle, 341 

of nose, 124, 125 

of tonsils, 220 
Cystocele of frontal sinus, 178 

Davidson's pow^der-blower, 56 
Deafness, causes of, 489 

from otitis media catarrhalis chron- 
ica, operation for, 417 
suppurativa chronica, opera- 
tion for, 427 
hysteric, 491 

miti die-ear and internal-ear, differ- 
entiation, 489 
operations for, history, 428 
Delaborde's tracheal dilator, 287 
Delstanche's masseur, 44 
Dench"s ear instruments, 416 
Dermatitis of auricle, 334 
Detergent washes, 494 
DeVilbiss atomizer, 48, 5 1 
Diabetes, otitis media from, 415 
Dilator, Allport's, 466 
laryngeal, Browne's, 251 
tracheal, Delaborde's, 287 
Diphtheria, 273 
antitoxin, 280 
complications, 278 
classification, 274 

croupous tonsillitis and, differenti- 
ation, 215, 216 
diagnosis, 278 
epistaxis in, 278 
etiology, 274 
extubation in, 284 
faucial, 274 
intubation in, 281 

accident following, 283 
extubation after, 284 
feeding in, 285 
inability to breathe after, 284 
treatment of patient, 284 
laryngeal, 274, 276 
malignant, 274 
membrane in, 274 
mild, 274 
nasal, 274, 276 
otitis media from, 412 
otorrhea in, 278 
paralysis in, 277 
pathology, 274 



JNDKX 



541 



Diphtheria, prognosis, 279 
propliylaxis, 279 
serum treatment, 280 
severe, 274 
symptoms, 274 
systemic infection, 277 
toxemia in, 277 
tracheotomy in, 285. See also 

I'racheotoniy 
treatment, 279 

constitutional, 280 
local, 279 
operative, 281 
prophylactic, 279 
serum, 280 
well-marked, 274 
Diphtheritic inflammation of Schnei- 

dcrian membrane, 71 
Diploetic mastoid, 452 
Dilhymol diiodid, 514 
Douche, nasal, anterior, 100 

postnasal, loi 
Drills, bone, 94 

electric-motor, 95 
for exostosis of septum, 95 
Drum-head, 294. See also Membrana 

tyuipani. 
Dry catarrh, 70 
Ductus cochlearis, 303, 304 
Dusting-powders, 5 1 1 
Dysacousma, 385 
Dysesthesia acoustica, 385 

Ear, 292 

anatomy of, 292 

auricle of, 292. See also Auricle 

of ear. 
auscultation of, 325 
bones of, 298 

diseases of, intracranial complica- 
tions, 475 

pathologic conditions of nose 
causing, 318 
of pharynx causing, 318 
examination of, 62 
external, 292. See also External 

ear. 
forceps for foreign bodies, 360 

Politzer's, 361 
instruments, Dench' 5,416 
internal, 303. See also Labyrinth. 
lobule of, 293 
middle, 294. See also Middle ear. 



Ear, ]X)lypi in, 405 

sectional study of, 444 

speculum, 40, 41 

syringe, soft-rubber, 57, 58 
Ear-spout, 357 
lOcchondroma of nose, 124 
Ecchondroscs of septum, 90 

treatment, 91-97 
Eczema of auricle, 339 
Edema of glottis, 248 

of larynx, acute, 248 
Electric-motor drills, 95 
Electrolysis for Eustachian stricture, 

329 
Empyema of sphenoidal cells, 183 
Encephaloscope, Whiting's, 480 
Endolymph, 303 
Entotic use of speaking trumpet in 

testing hearing, 316 
Enzymol, 497 
Epiglottis, 29, 229, 232 
muscles of, 235 
turbine-shaped, 253 
Epilepsy, laryngeal, 268 
Epistaxis, 1 17, 504 

adrenalin for, 503, 504 
in diphtheria, 278 
Epithelial plug in auditory canal, 357 
Epithelioma of auricle, 341 
Equinia of pharynx, 206 
Ergotin, 504 

Ermold's tonsillotome, 222 
Erysipelas of auricle, 337 
phlegmonous, 338 
of pharynx, 201 
Ethmoidal sinus, inflammation of, 179 
treatment, 181 
purulent disease of, 179 
Ethmoiditis, necrosing, 179 
Eucain, 501 

Eustachian bougies, 328 
catheter, 321 

Hartmann's, 322 

inflation of middle ear through, 

326 
introduction of, into tubes, 323 
medication through, 326 
spraying through, 326 
salpingitis, acute, 373 
tubes, 302 

Allen's probe as applicator in, 

328 
arteries of, 302 



54- 



INDEX 



Eustachian tubes, catheterization of, 
321 

introduction of catheter, 323 

obstacles to, 324 
dilation of, 328 
direct medication of, 326, 327 
examination of, 63 
introduction of catheter into, 323 
muscles that dilate, 302 
nerves of, 302, 303 
patency of, 319 

bougies in testing, 323 

catheter test, 321 

in chronic otitis media, 388 

Politzer's test, 320 

probes in testing, 323 

Valsalva's test, 319 
pharyngeal mouths of, 319 
stricture of, 391 

electrolysis for, 329 

head noises in, 394 

inflation in, 392 

massage in, 392 

phonomassage in, 393 

pneumomassage in, 393 

treatment, 392 
Euzone, 496 

Examination of patients, 61 
Exostoses of external auditory canal, 

349 
of nose, 124 
of septum, 90 
treatment, 91-97 
External auditory canal, 293 
cholesteatoma in, 358 
circumscribed inflammation of, 

acute, 341 
diseases of, 341 
epithelial plug in, 357 
exostosis of, 349 
foreign bodies in, 350 

removal, 352 
furunculosis of, 341 
hyperostosis of, 349, 350 
inflammation of, 341 . See also 

Otitis. 
mycosis of, 346 
of fetus, frontal section through, 

447 
osteomata of, 349 
washing out of, 356 
ear, anatomy of, 292 
congenital defects, 329 



External ear, diseases of, 329 
of newborn, 446 
meatus, frontal section through, 
438 
horizontal section through, 446 
Extradural abscess from otic disease, 

475 
Extubation in diphtheria, 284 
Eye syringe, soft-rubber, 57, 58 

Facial nerve, situation of, in new- 
born, 450 
wounding of, in mastoid opera- 
tion, 474 
paralysis from otic disease, 483 
diagnosis, 486 
prognosis, 487 
symptoms, 485 
treatment, 488 
False croup, 266 
hearing, 386 
vocal cords, 235 
Falsetto voice, 237 
Farcy of pharynx, 206 
Faucial tonsils, 186 
Fenestra ovalis of tympanum, 298 
Ferguson's antrum illuminator, 164 
Fetterolf's triangular files, 145 
Fibroid of auricle, 341 
Fibroma, nasopharyngeal, 124, 126 

of nose, 124 
Files, Fetterolf's triangular, 145 
Foramen of Rivini, 360, 369 
Forceps, Adams' septum, 154 
Asch's compressing, 141 
ear, for foreign bodies, 360 

Politzer's, 361 
Gleason's bone-cutting, 155 
Griinwald's cutting, 182 
laryngeal, Cusco's, 262 

Mackenzie's, 262 
middle ear, Allport's, 437 
Myles' alligator cutting, 182 
polyp, 360 

postnasal, Lowenburg's, 190 
rongeur, Hopkins', 462 
vSchroeter's, 212 
Sexton's, 406 
Foreign bodies in external auditory 
canal, 350 
removal of, 352 
in larynx, 262 
in nose, 109 



INDEX 



543 



Foreign bodies in pharynx, 212 
Foreign-lxKly forceps, 360 
Formal in as sterilizer, 60 
Formulas, 494 

aUeralives, 515 

animoniiim salts lozenges, 534 

analgesics, 499 

anesthetics, local, 499 

astringents, 508 

camphomenlhol lozenges, 533 

caustics, 508 

cocain lozenges, 534 

cough mixtures, 528 

detergent washes, 494 

dusting-powders, 511 

for cleansing mucous membranes, 

494 

for croup kettle, 528 

for epistaxis, 504 

for hemoptysis, 504 

for inhalers, 528 

for net)ulizers, 523 

gargles, 530 

guaiacum lozenges, 532 

hemostatics, 502 

hypnotics, 517 

local anesthetics, 499 

lozenges, 531 

miscellaneous, 518 

ointments, 507 

pigments, 506 

protectives, 498 

sedatives, 505 

slippery elni lozenges, 535 

tonics, 518 

washes, 494 
Fossa of nose, arteries of, 68 
nerves of, 68 

supratonsillaris, 187 
Fox's head-band, 18 
Frog face, 125 

Frontal disease, inflammation of, pur- 
ulent, Killian's operation for, 178 

section through external auditory 
canal of fetus, 447 
through external meatus, 438 
through skull, 442, 443 
through spina of child, 450 

sinus cannula, Hartmann's, 176 
chiseling into, 177 
cystocele of, 178 
illuminator, 170 
inflammation of, 171 



Frontal sinus, inflammation of, })uru- 
lent chronic, 175 
mucocele of, 178 
purulent disease of, chnjnic, 175 
Killian's operation for, 178 
P'rost-bite of auricle, 334 
Furunculosis of external auditcjiy 
canal, 341 

G Alton's whistle, 310 
Galvanocautery for removing hyper- 
trophies, 83 

handle, 87 

in chronic follicular pharyngitis, 198 

knives, 87 

tonsillotomy by, 224 
Gangrene of auricle, 339 
Gargles, 494, 530 
Gelles' test for hearnig, 316 
Glanders of pharynx, 206 
Glaserian fissure, 298 
Gleason's bone-curet, 464 

electric light, 418 
motor drill, 95 

head-band, 19 

nasal bone-cutting forceps, 155 
speculum, 34 
tubes, 150 

operation for deviated septum, 135 

polypus snare, 407 
Globe multinebulizer, 54, 55 
Globus hysteriee, 211 
Glosso-epiglottic fold, 30 

fossae, 30 
Glossopharyngeal nerve, tympanic 

branch, 301 
Glottis, 29, 235 

chink of, 235 

edema of, 248 
Glycerin as nebulizer, 523 
Glycothymolin, 495 
Goodwillie's tonsil-compressor, 221 
Gottstein's nasal curat, 191 

treatment of atrOy)hic rhinitis, 102 
Gouges, mastoid, Whiting's, 465 
Granulations on membrana tympani, 

366 
Greasy paste, 446 

Gruber's instrument for introducing 
artificial drum-head, 372 

specula, 40, 41 
Giiinwald's cutting forceps, 182 
Guaiacum lozenges, 532 



544 



INDEX 



Gumma, nasal, 104 
of auricle, 337 
of phai-ynx, 204, 209 

Habitus lymphaiicus, 192 
Hair-cells, 305 
Hajek's elevators, 146 
Halle's cannula, 167 

trocar, 167 
Hammer bone of ear, 298 
Hand-gouge, Randall's, 463 
Hard tonsil, 221 
Harland's laryngeal caret, 256 
Harmony, 311 

Hartmann's Eustachian catheter, 322 
frontal sinus cannula, 176 
tuning-forks, 312 
Hassler's site of predilection, 410 
Hay-asthma, III 
Hay-fever, ill 
adrenalin in, 503 
antitoxins for, 115 
hypersensitiveness, 113 
mineral acids in, 520 
pollantin for, 115 
prognosis, II 5 
treatment, 1 1 2-1 1 5 
Head noises in stricture of Eusta- 
chian tube, 394 
Head-band, Fox's, 18 

Gleason's, 19 
Hearing, Bing's test for, 316 
cells, 306 

entotic use of trumpet as test, 316 
false, 3 86 

Gelle's test for, 316 
Rinne's test for, 314 
Schwabach's test for, 316 
tests for, 62, 308, 310 
Bing's, 316 

entotic use of trumpet for, 316 
Gelle's, 316 

pressions centripetes, 316 
Rinne's, 314 
Schwabach's, 316 
voice as, 317 
watch as, 316 
Weber's, 313 
voice as test for, 317 
watch in testing, 316 
Weber's test for, 313 
Heart, effects of adrenalin on, 503 
Hematoma of nasal septum, 152 



Hemophilia, 124 
Hemoptysis, 504 
Hemorrhage into labyrinth, 490 
nasal, 117 

pressure-cone for, 121 
recurrent, 123 
treatment, 1 1 9-1 24 
secondary, from use of adrenalin, 
502 
Hemorrhagia narium, 117 
Hemostatics, 502 

hydrogen peroxid as, 497 
Herpes of auricle, 335 
tfopkins' rongeur forceps, 462 
Horizontal section through external 
meatus, 446 
semicircular canal, opening of, in 
mastoid operation, 474 
Horse cold, iii 
Hot-air apparatus, 57 

Van Sant's, 57 
Hydrobromic acid, 521 
Hydrochlorate of cocain, 499 
Hydrogen peroxid, 496 
Hydrorrhea, nasal, 115 
Hyperemia of auricle, 2>ZZ 
of labyrinth, 490 
of larynx, 239 
Hyperesthesia of larynx, 264 
of nasal mucous membrane, ill 
of pharynx, 210 
Hyperosmia, 1 1 1 
Hyperostosis in mastoiditis, 454 
of external auditory canal, 349, 

350 
Hypertrophied angle of septum, 128 
Hypertrophies, anterior nasal, re- 
moval of, 82 
posterior nasal, removal of, 88 
Hypertrophy of lingual tonsil, 225 
of pharyngeal tonsil, 189 
of tonsils, chronic, 221 

soft, 221 

of uvula, 227 
Hypnotics, 517 
Hysteric deafness, 491 

ICHTHYOL, 507 

Illumination for laiyngoscopy, 20 
Illuminator, Ferguson's antrum, 164 

frontal sinus, 170 
Impacted cerumen, 354 
Impetigo contagiosa of auricle, 336 



INDEX 



545 



Incudo.stapedial articulation, severing 

of, 422 
Incus, 299 

malleus, and iiienibrana tympani, 
removal of, 417 
in suppurative ca>cs, 434 
Infants, mastoid antrum of, 450 

membrana tympani of, 450 
Inferior meatus of nose, 66 
washing out of, 47 
turbinated bone, 66 
Intiltration of nasal septum, submu- 
cous, 153 
Inflammation of mucous membranes 
of nose, 70. See also Schiteidcriaii 
nuDibranc, inJiaiii7)iatio)i of. 
Inlluenza, otitis media from, 412 
Infraglottic laryngoscopy, 28 
Ingal's operation for deviated septum, 

134 
Inhalers, 55 

formulas for, 528 
Insects in ear, 350 

Instruments for examination, steiiliza- 
tion of, 58 
for treatment, sterilization of, 58 
sterilization of, 58 
Intensity of tone, 309 
Interarytenoid space, 29 
Internal ear, 303. See also Laby- 
rinth. 
massage, 393 
Intracranial complications of otic dis- 
ease, 475 
Intratympanic operations, history, 428 
Intubation in diphtheria, 281 
accident following, 283 
extubation after, 284 
feeding in, 285 
inability to breathe after, 284 
treatment of patient after, 284 
lodin, 519 
lodomnth, 515 
Ipecacuanha, 535 
Iter chordae anterius, 297 
posterius, 297 

Jacobson's nerve, 301 

Jan sen's operation for disease of an- 
trum of Highmore, 169 

Jarvis' snare, 83 

transfixing needles, 82 

Jugular vein, position of, 437 

35 



Keloid of auricle, t^t^t^ 
Keratosis obturans, 357 
Killian's operation for deviated sep- 
tum, 145 
for jmrulent disease of frontal 
sinus, 178 
Kirkpatrick's lingual tonsil scissors, 
^225 

Knives, IJallenger's septum, 146 
swivel, 147 
cautery, 87 
Seller's septum, 151 
tonsil, Abraham's, 220 
Konig's rods, 310 
Kiister's oj^eration, 169, 440, 441 
Kyle's malleable nasal tube, 149 
operation for deviated septum, 144 

Labyrinth, anatomy of, 303 

and middle-ear deafness, differen- 
tiation, 489 

anemia of, 490 

bloody discharge from, 491 

concussion of, 491 

hemorrhage into, 490 

hyperemia of, 490 

osseous, boundaries of, 303 
contents of, 303 

saccule of, 303 

syphilis of, 49I 

utricle of, 303 

vestibule of, 303 
functions, 307 
Labyrinthitis, primary acute, 493 
La grippe, otitis media from, 412 
Lamina reticularis, 306 

spiralis ossea, 303 
Lancet, laryngeal, Tobcld's, 250 
Lanolin, cocain in, 501 
Laryngeal chorea, 265 

cough, spasmodic, 265 

curet, Harland's, 256 

dilator, Browne's, 251 

diphtheria, 274, 276 

electrode, Mackenzie's, 273 

epilepsy, 268 

forceps, Cusco's, 262 
Mackenzie's, 262 

image, 29 

bringing into view, 26 
normal, 29 

lancet, Tobold's, 250 

mirror, 17 



546 



INDEX 



Laryngeal mirror, introduction of, 24 
temperature of, 26 

sound, 45 

vertigo, 268 
Laryngismus stridulus, 266 
Laryngitis, acute, 239 

catarrhal, acute, 239 

chronic, 244 
treatment, 246 

edematous, 248 

mucous, acute, 239 

phlegmonous, 248 

phthisica, 252 

sicca, 246 

specific, 250 

subacute, 242 

syphilitica, 250 

tubercular, 252 

differential diagnosis, 254 
treatment, 255-258 
Laryngology, 22 
Laryngopharynx, 184 
Laryngoscope, 17 

laryngeal mirror of, 17 

reflector of, 17, 18 

method of wearing, 19 
Laryngoscopy, 22 

illumination for, 20 

infraglottic, 28 

light for, 20 

concentrators in, 20 

obstacles to, 26 

source of light in, 21 

tongue in, controlling of, 24 
Laryngotomy, 288 

Laryngotraclieoscopy, tongue-depres- 
sor for, 30 
Laryngotracheotomy, 287, 288 
Larynx, 229 

anatomy of, 229 

anemia of, 239 

anesthesia of, 264, 500 

arteries of, 236 

autoscopy of, 30 

carcinoma of, 260 
treatment, 260 

cartilages of, 229 

diseases of, 239 

edema of, acute, 248 

foreign bodies in, 262 

hyperemia of, 239 

hyperesthesia of, 264 

in voice production, 237 



Larynx, inflammation of. See Laryn- 
gitis. 
ligaments of, 233 
lupus of, 254 
mucous membrane of, 235 
muscles of, 233 
nerves of, 236 
neuroses of, 264 
motor, 264 
sensory, 264 
papilloma of, 259 
treatment, 260 
paralysis of, 268 
abductor, 270 
adductor, 269 

from aneurism of aorta, 236 
treatment, 272 
paresthesia of, 264 
size of, 237 
spasm of, 265 
submucous tissue of, inflammation 

of, 248 
tuberculosis of, 252 

differential diagnosis, 254 
treatment, 255-258 
tumors of, 258 

ihyrotomy for, 263 
treatment, 260 
veins of, 236 
ventricles of, 235 
ventricular bands of, 29 ■ 
Lateral sinus, wounding of, in mastoid 

operation, 473 
Laxator tympani muscles, 300 
Leeches in otitis media catarrhalis 

acuta, 377 ^ ^ 
Leptomeningitis from otic disease, 476 

purulent, from otic disease, 477 
Leptothrix buccalis, 199 
Levator palati muscle, 302 
Light concentrators in laryngoscopy, 
20 
for laryngoscopy, 20 
source of, in laryngoscopy, 21 
Lignol, 506 
Lingual tonsil, hypertro])hy of, 225 

scissors, Kirkpatrick's, 225 
Listerin, 495 
Little Wonder pnmp, 52 
Lobule of auricle, cleft, 333 

of ear, 293 
Lowenburg's method of catheteriza- 
tion of Eustachian tubes, 323 



INDEX 



547 



Lowenburg's postnasal forcei)s, 190 
Loudness of musical notes, 238 
Lozenges, 531 

annnoniuni salts, 534 

caniphomenthol, 533 

cocain, 534 

guaiacuni, 532 

miscellaneous, 535 

slippery elm, 535 

voice, 535, 536 
Lucca's pressure jtrobe, 393 
Lumbar puncture, 476 
Lupus, 108 

of larynx, 254 

vulgaris, 108 
of auricle, 336 
of pharynx, 206 
Lythol, 495 

MacEwen's triangle, 469 
Mackenzie's laryngeal forceps, 262 
Malleo-incudal joint, 300 
Malleus, 298 

incus, and membrana tympani, re- 
moval of, 417 
in suppurative cases, 434 
Massage, internal, 393 

of middle ear, 392 
Masseur, aural, 44, 45 

of Delstanche, 44 
Mastoid antrum, 303 
of infants, 450 
chisels, Whiting's, 465 
curet, McKernon's, 462 
gouges, Whiting's, 465 
operation, 458 
accidents, 472 
after- technic, 470 
history, 458 
instruments for, 461 
opening horizontal semicircular 
canal, 474 
posterior cranial fossa in, 473 
preparation of patient, 461, 462 
technic, 461 

wounding facial nerve in, 474 
lateral sinus in, 473 
process, abscess in, perforation of, 
468 
diploetic, 452 
hyperostosis of, 454 
in adult, 451 
of temporal bone, 303 



Mastoid process, pathologic impor- 
tance of types, 452 

pneumatic, 45 I 

l)neumodii)loelic, 452 

sclerosed, 452 

structure of, 4-^1 

tip of, removal, 468 
Mastoiditis, 446 

brain complications in, 456 

caries in, 454 

complications, 454 

etiology, 452 

hyperostosis in, 454 

necrosis in, 454 

operation for, 458. See also Mas-, 

ioid operation. 
operative cases, 455 
otorrhea in, sudden cessation of, 455 
pathology, 453 
prognosis, 457 
sudden cessation of discharge in, 

455 
symptoms, 452, 455 
tenderness in, 456 
treatment, 457 
Mayer's tube, 143 
McKernon's mastoid curet, 462 
Measles, otitis media from, 412 
Meati of nose, 66 
Membrana basilaris, 303 
flaccida, 294 
propria, 295 
tectoria, 306 
tensor, 295 
tympani, 294 
abscess of, 366 

artificial, contrivance for introduc- 
ing, 372 
Toynbee's, 372 
chalk deposits on, 367 
curvature of, changes in, 361 
discharge from, 366 
diseases of, 360 
granular spots on, 366 
in chronic otitis media, 386 
in newborn, 446 
incision of, 415 
inflammation of, 362 

chronic, 365 
malleus, and incus, removal of, 

417 
in suppurative cases, 434 
nerves of, 295 



548 



INDEX 



Membrana tympani of children, ex- 
amination, 449 
perforation of, 369 

in otitis media, 396, 397 
treatment, 369 
polypi on, 366 
puncturing of, in otitis media, 

378 
rupture of, 367 
secundaria, 298 
ulcer of, 369 
vessels of, 295 
vibrans, 295 
Meniere's disease, 386, 492 
Meningitis, external, from otic dis- 
ease, 475 
otic, 456 
Menthol, 498, 511, 519 
Menzel-Hajek operation for deviated 

septum, 145 
Metal ear-spout, 357 
Metastasis, ear conditicms from, 492 
Methyl- violet, 513 
Middle ear, adenoids of, 380 
anatomy of, 294 

and internal-ear deafness, differ- 
entiation, 489 
catarrh of. See Otitis jnedia. 
cleansing of, 404 

hydrogen peroxid for, 497 
diseases of, 360 
forceps, Allport's, 437 
inflammation of, 373. See also 

Otitis media. 
inflation of, by Eustachian cath- 
eter, 326 
massage of, 392 
of newborn, 446 
operations upon, 415 
meatus of nose, 67 
turbinated bone, 66 
Miller's asthma, ill 
Mineral acids, 520 
Mixture, 1-2-3, 5^5 
Mixtures, cough, 528 
Motor neuroses of larynx, 264 

of nose, 1 10 
Mouth-breather, 80 
Mouth-washes, 494 
Mucocele of frontal sinus, 1 78 
Mucous membrane of nose, 267. See 
also Schneiderian niC7nbra7je. 
remedies for cleansing, 494 



Mucus, 71 

Multinebulizer, 54, 55 
Music, 308 
Musical notes, 237, 238 

qualities of, 238 
Mycosis of external auditory canal, 
346 

of pharynx, 199 
Myles' alligator nasal cutting forceps, 
182 

nasal speculum, 34 

tonsil punches, 224 
Myringitis, 362 

chronic, 365 
Myringotomy, 415 

for permanent opening, 417 

multiple openings, 417 
Myxoma of nose, 124 

Nabulin, 525 
Nares, 'i^'h 

occlusion of, congenital, 150 
posterior, plugging of, 123 
Nasal applicator, Allen's, 46 

with Gottstein's cotton plug, 
102 
catarrh, acute, 74 
atrophic, 98 
hypertrophic, 80 
chancre, 104 
curet, Gottstein's, I91 
diphtheria, 274, 276 
douche, anterior, 100 
gumma, 104 
hemorrhage, 1 17 

pressure-cone for, 121 
recuiTent, 123 
treatment, 11 9- 124 
hydrorrhea, 1 15 

mucous membrane, anesthesia of, 
III 
hyperesthesia of, ill 
paresthesia of, ill 
saws, 93 

Bosworth's, 93 
Bucklin's reversible, 93 
Sajous', 93 
scissors, 94 
septum, 64, 65 
abscess of, 152 
deflection of, ear disease from, 

deformities of, 153 



INDEX 



549 



Nasal septum, deviation of, 128 
Asch's operation for, 141 
Jiallenger's operation for, 145 
IJoswortli's operation for, 133 
Gleason's operation for, 135 
Ingal's operation for, 134 
Killian's operation for, 145 
Kyle's operation for, 144 
Menzel-Hajek operation for, 

145 
operations for, 133 

factors interfering with, 132 
patliology, 130 
Roberts' operation for, 140 
Roe's operation for, 145 
Sajous' operation for, 134 
Seiler's operation for, 134 
symptoms, 130 
Watson's operation for, 135 
window resection for, 145 
diseases of, 128 
dislocation of, 153 
ecchondroses of, 90 
treatment, 91-97 
exostoses of, 90 

treatment, 91-97 
hematoma of, 152 
hypertrophied angle of, 128 
infiltration of, submucous, 153 
osteoma of, hyperplastic, 90 
provisional callus of, 128 
redundancy of, 132 
resiliency of, 132 
speculum, 34 
Allen's, 35, 36 
Gleason's, 34 
Myles', 34 
syphilis, 104 
tubes, Gleason's, 150 
Kyle's, 149 
Nasophaiyngeal fibroma, 124, 126 
Nasopharynx, TiZ^ 184 

diseases of. 188 
Nebulizers, 53 

formulas for use in, 523 
Necrosing ethmoiditis, 179 
Necrosis in mastoiditis, 454 

of temporal bone, 408 
Needles, Jarvis' transfixing, 82 
Neuroses of larynx, 264 
motor, 264 
sensory, 264 
of nose, 1 10 



\ Neuroses of nose, reflex, 1 1 1 
sensory, 1 10 

of pharynx, 210 
Nevus of auricle, 341 
Newborn, external ear of, 446 

facial nerve in, 450 

middle ear of, 446 

osseous canal in, 448 

Schrapnell's membrane in, 449 

temporal bone of, 449 
Nitrate of silver, 509 
Nitromuriatic acid, 520, 521 
Normal laryngeal image, 29 
Nose, 64 

accessory sinuses of, diseases of, 

159 
differentiation, 159 
inflation of, by Politzer's air- 
bag, 165 
by Valsalva's method, 166 
alse of, 65 
anatomy of, 64 
anesthesia of, 499, 500 
angioma of, 124 
arteries of, 66 
bony arch of, 64- 

framework of, deformities of, 153 
injuries of, 153 
bridge of, 64 

flattening of, 154 
carcinoma of, 124, 127 
cartilaginous arch of, 64 
cavities of, 66 
cyst of, 124, 125 
deformities of, congenital, 158 
diseases of, 73 

causing disease of ear, 318 

effect on other parts of body, 73 

extension of, 73 
ecchondroma of, 124 
erectile tissue of, 67 
examination of, 61 
exostosis of, 124 
external, 64 
fibroma of, 124 
foreign bodies in, 109 
fossae of, arteries of, 68 

nerves of, 68 
functions of, 69 
interior, washing out of, 47, 50 
lymphatics of, 69 
meati of, 66 
motor neuroses of, 1 10 



550 



INDEX 



Nose, mucous membrane of, 67. See 

also Schtieiderian 7?ie?7ibrane. 
muscles of, 66 
myxoma of, 124 
nerves of, 66 
neuroses of, no 

reflex, in 

sensory, no 
olfactory region of, 67 
osteoma of, 124 
packing, 96 
papilloma of, 124, 126 
paralysis of, no 
polypus of, 124 

treatment, 126 
pug, 66 
regions of, 67 
respiratory region of, 67 
saddle-back, 154 
sarcoma of, 124, 127 
Schneiderian membrane of, 67. See 

also Schneiderimi jfiembi-ane. 
septum of, 64, 65. See also Nasal 

septum. 
sesamoid cartilages of, 64 
skin covering, 66 
•* stenosis of, no 
sterilization of, 60 
triangular cartilage of, 65 
tumors of, 124 
turbinated bones of, 66 
vestibular region of, 67 
Nosebleed, 117. '$)^t 2X^0 Epistaxis. 
Nose-washes, 494 
Nosophen, 514 

Octave, definition, 312 

O' Dv^^yer's intubation set, 282 

Oil, phosphorated, 519 

Ointments, 507 

Operator, preparation of, 60 

Organ of Corti, 304 

Oropharynx, 184 

diseases of, 194 
Orthoform, 512 
Ossicles, 298 
Osteoma, hyperplastic, of septum, 90 

of external auditory canal, 349 

of nose, 124 
Otalgia, pain in, relief of, 501 
Othematoma of auricle, 330 
Otitis externa, circumscribed, 341 
crouposa, 348 



Otitis externa diffusa acuta, 344 
chronica, 345 
diphtheritica, 347 
media, atrophic, 382 
catarrhalis acuta, 373 
bacteriology, 375 
dry heat in, 377 
leeches in, 377 
pathology, 375 
Politzer air-douche in, 378 
prognosis, 375 
puncturing drum-head in, 

378 
symptoms, 375 
treatment, 376-379 
chronica, 382 

deafness in, operation for, 

417 
etiology, 384 
hearing in, 384, 385 
membrana tympani in, 386 
operation for, 417 
patency of Eustachian tube 

in, 388 
prognosis, 389 
symptoms, 334 
objective, 386 
subjective, 384 
tinnitus in, 386 
treatment, 389-391 
vertigo in, 386 
cum ostitide mastoidae, 373 
ex tubce, 373 
subacuta, 379 

inflammation of mucous 
glands in, 38 1 
diy, 382 

from Bright' s disease, 415 
from diabetes, 415 
from diphtheria, 412 
from influenza, 412 
from la grippe, 412 
from measles, 412 
from pneumonia, 414 
from scarlatina, 4n 
from syphilis, 414 
from tuberculosis, 413 
from typhoid fever, 412 
hyperplastic, 382 
moist, 382 
mucosa acuta, y^T, 
non-purulenta, 373 
proliferous, 382 



INDEX 



55 



Otitis media serosa acuta, 373 
simple acute, 380 
suppurativa acuta, 396 
treatment, 398 
chronica, 400 

cleansing ear in, 404 

otorrhea in, 402 

tinnitus from, operation for, 

427 
treatment, 402-405 
removal of drum-head, mal- 
leus, and incus in, 434 
systemic diseases causing, 410 
Otoliths, 306 
Otomycosis, 346 
Otorrhea, bloody, 491 
chronic, causes, 431 

conditions preventing cessation, 

431. 
operations for, 432 
relapses, 433 

dusting-powders for, 513 

in diphtheria, 278 

in otitis media suppurativa chron- 
ica, 402 

sudden cessation of, in mastoiditis, 

455 
Otoscope, 39 

Brunton's. 40 

reflector of, 40 
Otoscopy, 39 

accessory instruments, 45 

introduction of speculum in, 42 

obstacles to, 42 

relative position of patient and ob- 
server, 41 

specula for, 40 
Oval window of tympanum, 298 
Ozena, 97 

syphilitic, 104 

Pachymeningitis from otic disease, 

475 
Packing nose, 96 
Palate retractor. White's, 38 
Panotitis, 493 
Papilloma of larynx, 259 
treatment, 260 

of nose, 124, 126 
Paracusis diplocusis, 385 

duplicata, 385 

Willisii, 385 
Paraffin injections, 519, 520 



Paraffin prothesis, 156 
syringe for, 156 
syringe, Smith's (Harmon), 156 
Paraklehyd, 517 
Paralysis, diphtheritic, 277 
facial, from otic disease, 483 
diagnosis, 4S6 
prognosis, 487 
symptoms, 485 
treatment, 488 
of arytenoideus muscle, 269 
of crico-arytenoid muscle, 270 
of cricothyroid muscle, 271 
of larynx, 268 
abductor, 270 
adductor, 269 

from aneurism of aorta, 236 
treatment, 272 
of lateral crico-arytenoid muscles, 

269 
of nose, no 
of pharj'nx, 2 II 

of soft palate after croupous tonsil- 
litis, 216 
of tensors of vocal cords, 271 
of thyro-arytenoid muscles, 271 
Paresthesia of larynx, 264 

of nasal mucous membrane, 1 1 1 
of pharynx, 21 1 
Parosmia, III 

Patients, examination of, 61 
Peach cold, ill 
Pendulum vibration, 308 
Perforation whistle, 369 
Perichondritis of auricle, 330 

chronic, 332 
Perilymph, 303 

Perimeningitis from otic disease, 475 
Peroxid of hydrogen, 496 
Petrolatum as nebulizer, 523 
Pharyngeal mouths of Eustachian 
tubes, 319 
tonsils, 186 

adenoid vegetations of, 189 
hypertrophy of, 189 
inflammation of bursa of, 193 
Pharyngitis, acute, 1 94 
atrophic, 198 
dry, 198 
follicular, 195 

chronic, 196 
granular, 195 
phlegmonous, 202 



55: 



INDEX 



Phar}-ngitis sicca, 198 

simple chronic, 195 

syphilitic, 204 
Pharyngoscopy, tongue -depressor for, 

30 

Pharynx, 184 

actinomycosis of, 207 

anatomy of, 184 

anesthesia of, 210 

arteries of, 186 

attachments of, 184 

diseases of, causing disease of ear, 

318 

divisions of, 184 

equinia of, 206 

erysipelas of, 201 

farcy of, 2o5 

foreign bodies in, 212 

glanders of, 206 

gumma of, 204, 209 

hyperesthesia of, 210 

int^ammation of. See Pharyngitis. 

lupus vulgaris of, 206 

lymphatics of, 186 

mucous membrane of, 186 

muscles of, 184 

mycosis of, 199 

nerves of, 186 

neuroses of, 210 

paralysis of, 21 1 

paresthesia of, 21 1 

posterior wall of, abscess of, 208 

ray fungus of, 207 

relations of, 184 

syphilis of, 204 

tuberculosis of, 205 

tumors of, 209 

ulcer of, simple, 202 
Phonomassage, 393 
Phosphorated oil, 519 
Pigments, 506 
Pilocarpin, 522 
Pinna, 292 
Piston-syringe, 44 
Pitch, 237, 238, 309 
Pituitary membrane, 67 
Pneumatic mastoid, 451 

speculum, Siegle's, 43 
Pneumodiploetic mastoid, 452 
Pneumomassage, 393 
Pneumonia, otitis media from, 414 
Politzer's air-bag, 321 
filling of, 165 



Politzer's air-bag in otitis media catar- 
rhalis acuta, 378 
inflation of accessory sinuses with, 
165 
ear forceps, 361 

test of patency of Eustachian tubes, 
320 
Pollantui for hay-fever, 115 
Polypi, aural, 405 

removal of, anesthesia for, 501 
forceps, 360 
nasal, 124 

treatment, 126 
on membrana tympani, 366 
snare, 406 
Blake's, 399 
Gleason's, 407 
Posterior cranial fossa, opening of, in 
mastoid operation, 473 
nares, plugging of, 123 
Postnasal catarrh, 188 
douche, loi 
space, zz, 184 
diseases of, 188 
washing out of, 48 
Powder-blower, 56 

Davidson's 56 
Pressions centripetes, 316 
Pressure probe, Lucca's, 393 
Pressure-cone for nasal hemorrhage, 

121 
Probe, Allen's, 46, 85, 86 

as applicator in Eustachian tube, 

328 
for removing cerumen, 353 
in exploring Eustachian tubes, 323 
pressure, Lucca's, 393 
Processus auditorius, 448 

cochleariformis, 298 
Protargol, 510 
Protectives, 498 

Provisional callus of septum, 128 
Prussak's space, 294 
Pseudacousma, 386 
Pug nose, 66 
Puncture, lumbar, 476 
Pynchon's cabinet, 53, 54 
Pyoktanin, 513 
Pyramid of light, 362 
Pyriform arytenoids, 253 

Quality of tone, 309 
Quinsy, 214 



INDEX 



553 



Ragged tonsil, 221 
Randall's hand -gouge, 463 
Range of voice, 238 
Ray fungus of pharynx, 207 
Recessus epitynipanicus, 296 
Reflector of laryngosc<)|K', 1 7, 18 
method of wearing, 19 

otoscopic, 40 
Reflex, the term, 73 
Reissner's membrane, 304 
Respiral, 525 

Retropharyngeal abscess, 208 
Rhinitis, 74 

acute, 74 

atrophic, 97 

average case, 103 
prognosis, 103 
treatment, 100-103 

cheniic, 70 

chronic, simple, 75 

hypertrophic, 79 

obstructive, 80 

pseudomembranous, 79 

purulent, 77 

scrofulous, 97, 98 

specific, 104 

subacute, 75 

syphilitic, 104 

tubercular, 107 
Rhinoliths, 109 
Rhinorrhagia, 1 17 
Rhinorrhea,75 
Rhinoscleroma, 108 
Rhinoscopic image, posterior, ^Z 
Rhinoscopy, 33 

anterior, 36 

posterior, 36 
image in, 38 
obstacles to, 38 

technic, 33 
Rima glottidis, 29, 235 
Rinne's test forbearing, 314 
Rivini's foramen, 360, 369 
Roberts' operation for deviated 

septum, 140 
Roe's operation for deviated septum, 

145 
Rohrer's diagnostic table, 62 
Rongeur forceps, 462 

Hopkins', 462 
Rose cold, III 

Round window of tympanum, 298 
Rupture of membrana tympani, 367 



SACCtJLK of labyrinth, 303 
Sacculus laryngis, 235 
Saddle-back nose, 154 
Sagittal section through temporal bone, 
432 
through tympanum, 444 
S.ijous' nasal .^aw, 93 

operation for deviated septum, 134 
Salpingitis, Kustachian, acute, 373 
Santorini's cartilages, 30, 232 
Sarcoma of auricle, 341 

of nose, 124, 127 
Saws, nasal, 93 

Bosworth"s, 93 
Rucklin's reversible, 93 
Sajous', 93 
Scala media, 304 
tympani, 304 
vestibuli, 304 
Scarlatina, otitis media from, 41 1 
Schneideriau membrane, 67 
inflammation of, 70 
catarrhal acute, 70 

chronic, 70 
croupous, 71 
diphtheritic, 7 1 
pathology, 71 
physiology, 69 
Schrapnell's membrane, 294 
in newborn, 449 
perforation of, 369 
Schroeter's forceps, 212 
Schwabach's test for hearing, 316 
Scirrhous tonsil, 221 
Scissors, Asch's, 141, 142 

lingual tonsil, Kirkpatrick's, 225 
nasal, 94 
Sclerosed mastoid, 452 
Secondary hemorrhage from use of 

adrenalin, 502 
Sedatives, local, 505 
Seiler's operation for deviated septum, 

134 
septum knife, 151 
Semicircular canal, horizontal opening 
of, in mastoid operation, 474 
membranous, 306 

functions, 307 
osseous, 303 
Sense of smell, derangements of, no 
Sensory neuroses, no 
Separators, Asch's, 142 
Septum forceps, Adams', 154 



554 



INDEX 



Septum knife, Ballenger's, 146 
Seller's, 151 

nasal. See iVasal sepiiun. 
Sesamoid cartilages, 64 
Sessile exostoses of auditory canal, 349 
Sexton's forceps, 406 
Shute of tympanum, 296 
Siegle's pneumatic speculum, 43 
Silver nitrate, 509 
Singing voice, 238 
Sinks, 53 
Sinus thrombosis from otic disease, 

481 
Skin covering nose, 66 
Skull, frontal section through, 442, 

443 
Slippery elm lozenges, 535 
Smell, derangements of, no 
Smith's (Harmon) screw-syringe for 

paraffin injection, 156 
Snare, Jarvis', 83 
polypus, 406 
Blake's, 399 
Gleason's, 407 
tonsillotomy by, 224 
Sneezing, III 

definition, 74 
Snow cold. III 
Snuffles, 74 

Soft-rubber ulcer syringe, 57, 58 
Somnos, 517 
Sore throat, acute, 194 
chronic, 195 
clergyman's, 196 
Sound, 30S 
laryngeal, 45 
sources of, 308 
Spasm of adductor muscles, 266 
of larynx, 265 

of tensors of vocal cords, 265 
Spasmodic laryngeal cougli, 265 
Speculum, Boucheron's, 41 
ear, 40, 41 
for otoscopy, 40 
Gruber's, 40, 41 
nasal, 34 

Siegle's pneumatic, 43 
Sphenoidal sinus, empyema of, 183 
Spittoon, swinging, 53 
Stacke's operation, 432, 438 
indications, 438 
technic, 439 
Stapedectomy, 422 



Stapedius muscle, 300 
Stapes, 300 

bony ankylosis of, 426 
extraction of, 422 
mobilizing of, 422 
Stenosis of nose, no 
Sterilization of mstruments, 58 
of nose, 60 
of operator, 60 
Stethoscope, aural, 319 
Stirrup bene of ear, 300 
Stovain, 501 
Stricture of Eustachian tube, 391. 

See Eustachian tubes, stricture of. 
Subdural abscess in otic disease, 475 
Sulphonal, 517 
Superior meatus of nose, 67 

turbinated bone, 66 
Suprameatal space, 469 
Suprarenal gland, powdered, 503 
Suprarenalin, 502 
Swinging spittoon, 53 
Syphilis, nasal, 104 

of auricle, 337 

of internal ear, 491 

of larynx, 250 

of phar}'nx, 204 

otitis media from, 414 
Syringes, 49 

ear, soft-rubber, 57, 58 

eye, soft-rubber, 57, 58 

ulcer, soft-rubber, 57, 58 

Tegmen tympani, 296 
Temporal bone, caries of, 408 
mastoid process of, 303 
necrosis of, 408 
of newborn, 449 
sagittal section through, 432 
Tenotomy of tensor tympani, 417 
Tensor palati muscle, 302 
tympani, 300 
tenotomy of, 417 
Tertiary syphilitic rhinitis, 104, 106 
Therapeutic test for lupus, 108 
Thornwaldt's disease, 193 
Throat, catarrh of, chronic, 195 
relaxed, 195 
sore, acute, 194 
chronic, I95 
clergyman's, 196 
Thrombosis, sinus, from otic disease, 
481 



INDEX 



555 



Tliymozonc, 496 
'I'liyro-arytcnouicus muscle, 234 
Thyruitl cartilage, 229 
Thyrotoniy, 263 
Timbre, 238, 309 
Tinnitus, 394 

from otitis media suppurativa 

chronica, operation fur, 427 
in otitis media, 386 
operation for, 417 
history, 428 
Tobold's laryngeal lancet, 250 
Tone, 309 

Tongue, controlling of, in laryngos- 
coi)y, 24 
examination of, 61 
Tongue-depressor, Bosworths, 28 
folding, 27 

for laryngotracheoscopy, 30 
for pharyngoscopy, 30 
Torek's, 27 
Tonics, 518 
Tonsil knives, Abraham's, 220 

punches, Myles', 224 
Tonsil-compressor, Goodwillie's, 221 
Tonsillitis, acute, 214 
abortion of, 218 
treatment, 217-219 
chronic, with hypertrophy, 221 

without hypertrophy, 219 
croupous, 214, 215 

diphtheria and, differentiation, 

215, 216 
treatment, 217-219 
erythematous, 215 
follicular, 214 
parenchymatous, 215 
phlegmonous, 214 
treatment, 217-219 
Tonsillotome, Ermold's, 222 
removal of tonsils by, 222 
Tonsillotomy by galvanocautery, 224 
by snare, 224 
by tonsillotome, 222 
piecemeal, 225 
Tonsils, 214 
cysts of, 220 
diseases of, 214 
faucial, 186 
functions, 187 
hard, 221 

hypertrophy of, chronic, 221 
soft, 221 



Tonsils, innanimation of. See Tun- 
sill it is. 

lingual, hypertrophy of, 225 

pharyngeal, 186 

adenoid vegetations of, 189 
hypertrophy of, 189 

r.igged, 221 

removing of, by tonsillotome, 222 

scirrhous, 221 
Toynbee's artificial drum-head, 372 

auscultation-tube, 320 
Trachea, autoscopy of, 30 
Tracheal dilator, Delaborde's, 287 
Tracheotomy, 285 

after-treatment, 291 

anesthetic in, 286 

high operation, 285, 287 

instruments for, 286 

low operation, 285, 288 

preparation of patient, 286 
Tracheotomy-tube, 290 
Transfixing needles, Jarvis', 82 
Trephining, 479 
Triangle of MacEwen, 469 
Triangular cartilage of nose, 65 
Trichloracetic acid for removing 

hypertrophies, 86 
Trional, 517 
Trocar, Halle's, 167 
True vocal cords, 235 
Tuberculosis of larynx, 252 
differential diagnosis, 254 
treatment, 255-258 

of pharynx, 205 

otitis media from, 413 
Tumors of auricle, 341 

of larynx, 258 

thyrotomy for, 263 
treatment, 260 

of pharynx, 209 
Tuning-forks, 310, 312 

Hartmann's, 312 
Turbinated bones, 66 

removal of, 96 
Turbinectomy, 96 
Turbine-shaped epiglottis, 253 
Turbinotomy, 96 
Turck's tongue-depressor, 27 
Tympanum, arteries of, 301 

atrium of, 296 

attic of, 296 

cavity of, 296 

diseases of, 373 



556 



INDEX 



Tympanum, fenestra ovalis of, 298 

floor of, 296 

inner wall of, 298 

muscles of, 300 

nerves of, 301 

outer wall of, 297 

oval windoM' of, 298 

plexus of, 301 

roof of, 296 

round window^ of, 298 

sagittal section through, 444 

shute of, 296 
Typhoid fever, otitis media from, 

412 

Ulcer of membrana tympani, 369 

of pharynx, simple, 202 

of uvula, 226 

syringe, soft-rubber, 57, 58 
Useless cough, 197 
Utricle of labyrinth, 303 
Uvula, bifid, 226 

deformities of, 226 

diseases of, 225 

elongation of, 227 

hypertrophy of, 227 

inflammation of, 225 

removal of, 228 

ulceration of, 226 
Uvulitis, 225 

pseudomembranous, 226 

Valsalva's method of inflating ac- 
cessory sinuses, 166 
test of patency of Eustachian tubes, 

319 
Van Sant's hot-air apparatus, 57 
Vaselin, 498 
Ventricles of larynx, 235 



Ventricular bands, 235 

of larynx, 29 
Vernix caseosa, 446 
Vertigo in otitis media, 386 

laryngeal, 268 
Vestibule of labyrinth, 303 

functions, 307 
Vibration, aerial, 308 

pendulum, 308 
Vibrissae, 36, 66 
Vocal cords, 29, 235 

cadaveric position of, 271 
spasm of tensors of, 265 
tensors of, paralysis of, 271 
process of arytenoid cartilage, 232 
Voice, 237 
falsetto, 237 
in testing hearing, 317 
lozenges, 535, 536 
production, 237 
qualities of, 238 
singing, 238 

Washes, detergent, 494 
Watch in testing hearing, 316 
Water-pump for compressed air, 50 
Watson's operation for deviated sep- 
tum, 135 
Weber's test for hearing, 313 
White's palate retractor, 38 
Whiting's encephaloscope, 480 
mastoid chisels, 465 
gouges, 465 
Window resection for deviated sep- 
tum, 145 
Wounds of auricle of ear, 332 
Wrisberg's cartilages, 30, 232 

i Xeroform, 515 



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of 547 pages, illustrated, including two full-page plates in colors. 
Cloth, $3.50 net; Half Morocco, ^5.00 net. 

This volume presents diseases of the Nose, Phar^'nx, and Ear as the author 
has seen them during an experience of nearly twenty-five years. Topographic 
anatomy has also been accorded liberal space. 

Pennsylvania Medical Journal 

" This is the most practical volume on the nose, pharynx, and ear that has appeared 
recently. ... It is exactly what the less experienced observer needs, as it avoids the con- 
fusion incident to a categorical statement of everybody's opinion." 

Kyle's Nose and Throat 



Diseases of the Nose and Throat. By D. Braden Kyle, 
M.D., Professor of Laryngology in the Jefferson Medical Col- 
lege, Philadelphia ; Consulting Laryngologist, Rhinologist, and 
Otologist, St. Agnes' Hospital. Octavo, 669 pages; over 184 
illustrations, and 26 lithographic plates in colors. Cloth, ^4.00 
net ; Half Morocco, $5.50 net. 

RECENTLY ISSUED— THIRD REVISED EDITION 



This work has now reached its third edition. With the practical purpose of 
the book in mind, extended consideration has been given to treatment, each 
disease being considered in full, and definite courses being laid down to 
meet special conditions and symptoms, 

Dudley S. Reynolds. M.D., 

Formerly Professor of Ophthalmology and Otology, Hospital College of Medichie, 
Louisz'ille. 
" It is an important addition to the text-books now in use. and is better adapted to the 
uses of the student than any other work with which I am familiar. I shall be pleased -io 
commend Dr. Kyle's work as the best text-book." 



SAUuDERS' BOOKS ON 



Greene and Brooks' 
Genito-Urinary Diseases 

A Text=Book of Genito=Urinary Diseases. By Robert 
H. Greene, M.D., Professor of Genito-Urinary Surgery at 
Fordham University; and Harlow Brooks, M.D., Assistant 
Professor of Pathology, University and Bellevue Hospital Medi- 
cal School. Octavo of 550 pages, profusely illustrated. 

JUST READY 

This new work covers completely the subject of genito-urinary diseases, 
presenting both the medical and surgical sides. It has been designed as a 
work of quick reference, and has therefore been written in a clear, condensed 
style, so that the information can be readily grasped and retained. Kidney 
diseases are very elaborately detailed, and especially well presented is surgery 
of the kidney. The text is profusely illustrated with original line-drawings. 

Gleason on Nose, Throat, 
and Ear 



A Manual of Diseases of the Nose, Throat, and Ear. By 

E. Baldwin Gleason, M.D., LL.D., Clinical Professor of 
Otology, Medico-Chirurgical College, Philadelphia. i2mo of 
556 pages, profusely illustrated. 

JUST ISSUED 

Anatomy, physiology, and pathology of the upper respiratory tract and ear 
have been carefully presented, the author rightly believing such knowledge 
essential to the efficacious treatment of diseases of these organs. Methods 
of treatment have been simplified as much as possible, so that in most instan- 
ces only those methods, drugs, and operations have been advised which have 
proved essential. A valuable feature consists of the collection of formulas. 

American Text=Book of Qenito=Urinary Diseases, 
Syphilis, and Diseases of the Skin. Edited by L. Bolton 
Bangs, M.D., late Professor of Genito-Urinary Surgery, Bellevue 
University, New York; and W. A. Hardaway, M.D., Professor 
of Diseases of the Skin, Missouri Medical College. Two octavos, 
1229 pages, 300 engravings, 20 colored plates. Cloth, 30s. net. 



DISEASES OE THE SKIiV. 



Mracek and Stelwa^on's 
Diseases of the Skin 



Atlas and Epitome of Diseases of the Skin. By Prof. 
Dr. Franz Mracek, of Vienna. Edited, with additions, by 
Henry W. Stelwagon, M. D., Professor of Dermatology in 
the Jefferson Medical College, Philadelphia. With 77 colored 
plates, 50 half-tone illustrations, and 280 pages of text. I?i 
Saunders' Hand- Atlas Series. Cloth, $4.00 net. 

RECENTLY ISSUED-NEW (2nd) EDITION 

American Journal of the Medical Sciences 

" The advantages which we see in this book and which recommend it to our minds are: 
First, its handiness ; secondly, the plates, which are excellent as regards drawing, color, and 
the diagnostic points which they bring out 

Mracek and Bancs' 
Syphilis ^ Venereal Diseases 

Atlas and Epitome of Syphilis and the Venereal Dis= 
eases. By Prof. Dr. Franz Mracek, of Vienna. Edited, with 
additions, by L. Bolton Bangs, M. D., late Prof, of Genito- 
urinary Surgery, University and Bellevue Hospital Medical Col- 
lege, New York. With 71 colored plates and 122 pages of text. 
Cloth, $3.50 net. In Saunders' Hand-Atlas Series. 

According to the unanimous opinion of numerous authorities, the illus- 
trations in this work surpass in beauty anything of the kind that has been pro- 
duced, not only in Germany, but throughout the literature of the world. 

Robert L. Dickinson, M. D., 

Art Editor of" The American Text-Book of Obstetrics." 

'"The book that appeals instantly to me for the strikingly successful, valuable, and 
graphic character of its illustrations is the ' Atlas of Syphilis and the Venereal Diseases.' 
I know of nothing in this country that can compare with it." 



12 SAUNDERS' BOOKS ON 

Holland's 
Chemistry and Toxicolog'y 

A Text=Book of Medical Chemistry and Toxicology. 

By James W. Holland, M.D., Professor of Medical Chemistry 
and Toxicology, and Dean, Jefferson Medical College, Philadel- 
phia. Octavo of 592 pages, illustrated. Cloth, ^3.00 net. 

RECENTLY ISSUED 

Dr. Holland's work is an entirely new one, and is based on his thirfy-five 
years' practical experience in teaching chemistry and medicine. Recognizing 
that to understand physiologic chemistry students must first be informed upon 
points not referred to in most medical text-books, the author has included in his 
work the latest views of equilibrium of equations, mass-action, cryoscopy, os- 
motic pressure, etc. Much space is given to toxicology. 

American Medicine 

" Its statements are clear and terse; its illustrations well chosen; its development logi- 
cal, systematic, and comparatively easy to follow. . . . We heartily commend the work." 

Griinwald and Newcomb's 
Mouth, Pharynx, and Nose 

Atlas and Epitome of Diseases of the Mouth, Pharynx, 

and Nose. By Dr. L. Grunwald, of Munich. F7^07n the 
Second Revised and Enlarged German Edition. Edited, with 
additions, by James E. Newcomb, M. D., Instructor in Laryn- 
gology, Cornell University Medical School. With 102 illustrations 
on 42 colored lithographic plates, 41 text-cuts, and 219 pages of 
text. Cloth, $3.00 net. In Saundei's' Hand-Atlas Se7'ies. 

In designing this atlas the needs of both student and practitioner were kept 
constantly in mind, and as far as possible typical cases of the various diseases 
were selected. The illustrations are described in the text in exactly the same 
way as a practised examiner would demonstrate the objective findings to his 
class, the book thus serving as a substitute for actual clinical work. The 
illustrat ons themselves are numerous and exceedingly well executed. 

American Medicine 

" Its conciseness without sacrifice of clearness and thoroughness, as well as the excel- 
lence of text and illustrations^ are commendable." 



EYE, EAR, NOSE, AND TI/ROAT. 



Jackson on the Eye 

A Manual of the Diagnosis and Treatment of Diseases 
of the Eye. By Edward Jackson, A.M., M.D., Professor of 
Ophthalmology, University of Colorado. i2mo of 615 pages, 
with 184 illustrations. Cloth, $2.50 ret. 

JUST ISSUED— NEW (2d) EDITION 
The Medical Record, New York 

" It is truly an admirable work. . . . Written in a clear, concise manner, it bears evi- 
dence of the author's comprehensive g^rasp of the subject. The term ' multuin in parvo ' is 
an appropriate one to apply to this work. It will prove of value to all who are interested in 
this branch of medicine." 



Friedrich and Curtis on 
Nose, Larynx, and Ear 



Rhinology, Laryngology, and Otology, and Their Sig= 
nificance in General Medicine. By Dr. E. P. Friedrich, of 
Leipzig. Edited, with additions, by H. Holbrook Curtis, M.D., 
Consulting Surgeon to the New York Nose and Throat Hospital. 
Octavo volume of 350 pages. Cloth, $2.50 net. 



Grant on the Face, Mouth, and Jaws 



A Text=Book of the Surgical Principles and Surgical 
Diseases of the Face, Mouth, and Jaws. For Dental 
Students. By H. Horace Grant, A.M., M.D., Professor of 
Surgery and of Clinical Surgery, Hospital College of Medicine, 
Louisville. Octavo of 231 pages, with 68 illustrations. Cloth, 
^2.50 net. 



»4 SAUNDERS' BOOKS ON 

Ogden on the Urine 

Clinical Examination of Urine and Urinary Diagnosis. 

A Clinical Guide for the Use of Practitioners and Students of 
Medicine and Surgery. By J. Bergen Ogden, M. D., Late 
Instructor in Chemistry, Harvard University Medical School ; 
Formerly Assistant in Clinical Pathology, Boston City Hospital. 
Octavo, 418 pages, fully illustrated, including a number of 
colored plates. Cloth, $3.00 net. 

SECOND REVISED EDITION— RECENTLY ISSUED 

In this edition important changes have been made in connection with the 
tletermination of Urea, Uric Acid, and Total Nitrogen ; and the subjects of 
Cryoscopy and Beta-Oxybutyric Acid have been given a place. Special at- 
tention has been paid to diagnosis by the character of the mine and the diag- 
nosis of diseases of the kidneys and urinary passages. 

The Lancet, London 

" We consider this manual to have been well compiled ; and the author's own experience, 
so clearly stated, renders the volume a useful one both for study and reference." 

Vecki's Sexual Impotence 

The Pathology and Treatment of Sexual Impotence. 

By Victor G. Vecki, M. D. From the Second Revised and 
Enlarged German Edition. i2mo volume of 329 pages. Cloth, 
^2.00 net. 

THIRD EDITION. REVISED AND ENLARGED 

This volume will come to many as a revelation of the possibilities of thera- 
peutics in this important field. The whole subject of sexual impotence and 
its treatment is discussed by the author in an exhaustive and thoroughly sci- 
entific manner. In this edition the book has been thoroughly revised, and 
new matter has been added, especially to the portion dealing with treatment. 

Johns Hopkins Hospital Bulletin 

"A scientific treatise upon an important and much neglected subject. . . . The treatment 
of impotence in general and of sexual neurasthenia is discriminating and judicious." 



CHEMISTRY, SKIN, AND VENEREAL DISEASES. 15 

American Pocket Dictionary just issued, stn Ed. 

The American Pocket Medical Dictionary. Edited by W. A. 
Newman Borland, M. D., Assistant Obstetrician to the Hospital of 
the University of Pennsylvania. Containing the pronunciation and defi- 
nition of the principal words used in medicine and kindred sciences. 
Flexible leather, with gold edges, ^i. 00 net ; with thumb index, ^1.25 net. 

" I am struck at once with admiration at *the compact size and attractive exterior. 
I can recommend it to our students without reserve." — James W. Holland, M. D., 
Professor 0/ Me Jical Chemistry and Toxicology, at the Jefferson Medical Col- 
lege, Philadelphia. 

Stelwagon's Essentials of Skin New*^(6th^ Edition 

Essentials ok Diseases of the Skin. By Henry \V. Stelwagon, 
M. D., Ph.D., Professor of Dermatology in the Jefferson Medical 
College and Woman's Medical College, Philadelphia. Po.st-octavo of 
276 pages, with 72 text-illustrations and 8 plates. Cloth, ^i.oo net. 
In Saunders' Question-Compend Series. 

" In line with our present knowledge of diseases of the skin. . . . Continues to main- 
tain the high standard of excellence for which these question compends have been 
noted." — The Medical News. 

Wolffs Medical Chemistry sixth^Edmon. Revised 

Essentials of Medical Chemistry, Organic and Inorganic. 
Containing also Questions on Medical Physics, Chemical Physiology, 
Analytical Processes, Urinalysis, and Toxicology. By Lawrence 
Wolff, M. D., Late Demonstrator of Chemistrj^, Jefferson Medical 
College. Revised by Smith Ely Jelliffe, M. D., Ph. D., Professor 
of Phamacognosy, College of Pharmacy of the City of New York. 
Post-octavo of 222 pages. Cloth, $1.00 net. In Saunders^ Question- 
Compend Series. 

" The author's careful and well-studied selection of the necessary requirements of 
the student has enabled him to furnish a valuable aid to the student." — New York 
Medical Jonrttal. 

Martin's Minor Surgery, Bandaging, and the 

Venereal Diseases second Edition. Revised 

Essentials of Minor Surgery, Bandaging, and Venereal Dis- 
eases. By Edward Martin, A. M., M. D., Professor of Clinical Sur- 
gery, University of Pennsylvania, etc. Post-octavo, 166 pages, with 78 
illustrations. Cloth, ^i.oo net. In Saunders'' Question Cot?ipends. 

" The best condensation of the subjects of which it treats yet placed before the pro' 
fession." — The Medical News. 

Stevenson's Photoscopy just Ready 

Photoscopy (Skiascopy or Retinoscopy). By Mark D. Steven- 
son, M. D., Ophthalmic Surgeon to the Akron City Hospital. I2moof 
200 pages ; illustrated. Cloth, $1.2^ net. 

Dr. Stevenson's work fully and clearly explains the use of this objective test and 
elucidates the reasons of the various phenomena observed. The illustrations have 
been drawn with special attention to their practical usefulness. 



1 6 URINE, EYE, EAR, NOSE, AND THROAT. 

Wolfs Examination of Urine 

A Laboratory Handbook of Physiologic Chemistry and Urine- 
examination. By Charles G. L. Wolf, M. D., Instructor in Physi- 
ologic Chemistry, Cornell University Medical College, New York i2mo 
volume of 204 pages, fully illustrated. Cloth, ^1.25 net. 

" The methods of examining the urine are very fully described, and there are at the 
end of the book some extensive tables drawn up to assist in urinary diagnosis." — 
British Medicul Journal. 

Jackson's Essentials of Eye Third Revised Edition 

Essentials of Refraction and of Diseases of the Eye. By 
Edward Jackson, A. M., M. D., Emeritus Professor of Diseases of the 
Eye, Philadelphia Polyclinic. Post-octavo of 261 pages, 82 illustrations. 
Cloth, ^l.oo net. /« Saunders' Question- Coinpend Series. 

" The entire ground is covered, and the points that most need careful elucidation 
are made clear and easy." — Johns Hopkins Hospital Bulletin. 

Gleason's Nose and Throat Third Edition, Revised 

Essentials of Diseases of the Nose and Throat. By E. B. 
Gleason, S. B., M. D., Clinical Professor of Otology, Medico-Chirurgical 
College, Philadelphia, etc. Post-octavo, 241 pages, 112 illustrations. 
Cloth, ^ 1. 00 net. In Saunders'' Question- Covipend Series. 

" The careful description which is given of the various procedures would be sufficient 
to enable most people of average intelligence and of slight anatomical knowledge to 
make a very good attempt at laryngoscopy." — The Lancet, London. 

Gleason's Diseases of the Ear Revised °"' 

Essentials of Diseases of the Ear. By E. B. Gleason, S. B., 
M. D., Clinical Professor of Otology, Medico-Chirurgical College, Phila- 
delphia, etc. Post-octavo volume of 214 pages, with 114 illustrations. 
Cloth, ^ I. GO net. In Saunders' Question- Co??tpend Series. 

" We know of no other small work on ear diseases to compare with this, either in 
freshness of style or completeness of information." — Bristol Medico-Chirurgical 
Journal. 

Wilcox on Genito-Urinary and Venereal Dis- 
eases J"st Issued 

Essentials of Genito-Urinary and Venereal Diseases. By 
Starling S. Wilcox, M.D., Professor of Genito-Urinary Diseases and 
Syphilology, Starling Medical College, Columbus, Ohio. i2nio of 313 
pages, illustrated. Cloth, ;g 1. 00 net. In Saunders' Question- Cornpends. 

Senn's Genito-Urinary Tuberculosis 

Tuberculosis of the Genito-Urinary Organs, Male and 
Female. By N. Senn, M.D., Ph.D., LL.D., Professor of Surgery in 
Rush Medical College. Octavo of 317 pages, illustrated. Cloth, 
$3.00 net. 



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